36 CHAPTER 3. EXAMINATION AND DIAGNOSIS Section 1.

Periodontal Probing

CHAPTER 3.
EXAMINATION AND DIAGNOSIS

Section 1. Periodontal Probing producibility in terms of defining the effects of reproduci-

The existence of a pocket implies a history of periodon- bility on the sensitivity and specificity of different diagnostic
tal disease. While some visual signs of inflammation, such thresholds for true change in probing depth. The mesio-facial
as redness and swelling, are helpful in detecting disease, surfaces of the Ramfjord teeth were measured in 15 patients
they are not always present in conjunction with inflamma- by 3 examiners. With a threshold of probing depth increase
tion at the base of the pocket. Van der Velden (1980) noted > 1 mm, it was determined that an increase could be cor-
that 4 to 5 weeks after scaling and root planing, most red- rectly diagnosed 91.3% of the time with a false-positive
ness and swelling disappeared, although sites still bled rate of 0.5%. A threshold of > 2 mm led to higher speci-
when evaluated by the periodontal pocket bleeding index. ficity, but with a great reduction in sensitivity.
Therefore, it is important to evaluate the bottom of the Reproducibility and concomitant examiner error has
pocket as well as the visual signs of inflammation. been reduced with the advent of controlled force probes
Listgarten (1993) emphasized correct terminology when with computer interfaces such as the Florida probe (Mag-
describing periodontal probing in the literature and encour- nusson et al., 1988) and Foster-Miller (Alabama) probe
aged use of the terms proposed in the 1989 Proceedings of (Jeffcoat et al., 1986).
the World Workshop in Clinical Periodontology (American
Academy of Periodontology, 1989). He discounted the term
"probing pocket depth," indicating that the true anatomic PROBING FORCE
measurement of the pocket can only be accomplished his- Van der Velden and de Vries (1978) evaluated the ef-
tologically. "Probing depth" was suggested as a more cor- fects of probing force on periodontal patients utilizing a
rect term since it measures the depth of the pocket plus the pressure-sensitive probe with a tip diameter of 0.63 mm.
inconsistent amount of connective tissue penetration. The The patients were free of clinical inflammation at the time
term "probing attachment level" should be replaced by the of the measurements. Sites were probed at forces of 0.15N,
more descriptive terms "clinical attachment level" when 0.25N, 0.50N, and 0.75N. A positive relation between prob-
the measurement is made from a fixed reference on the ing force and probing depth was observed. In a study using
tooth (CEJ or restoration). "Relative attachment level" ap- condemned teeth, Van der Velden (1979) evaluated the lo-
plies when the measurement is made from some other ref- cation of the tip of the probe with different probing forces.
erence point (e.g., stent margin or occlusal tooth surface). He reported that a force of 0.75N was in closest agreement
A number of variables exist that will affect probing depth with attachment level measurements. Chamberlain et al.
measurements, and each must be considered when evaluating (1985) also showed that forces of 0.75N were more repro-
results. These variables include: probing reproducibility, prob- ducible, with the probe extending to the most coronal con-
ing force, probe angulation, status of gingival health, site lo- nective tissue (CT) attachment in health and disease. The
cation, local anatomy, and type of probe used. authors suggested that one of the difficulties with under-
standing discrepancies with probing attachment levels in
earlier studies may have been due to non-standardized prob-
PROBING REPRODUCIBILITY ing forces. Mombelli et al. (1992) used a probe with a steel
Isidor et al. (1984) studied the reproducibility of meas- spring and strain gauges to provide a constant increase in
urements using a flexible splint, gentle pressure, and one probing force that could be diagrammed. The study indi-
examiner. Sixty percent (60%) of the measurements were cated that higher probing forces will lead to more repro-
in complete agreement between the first and second meas- ducible readings, but suggest that lighter forces could detect
urements before and after surgery. Ninety-five (95) of the more subtle changes in attachment levels. Freed et al.
surfaces differed by < 1 mm or less and no measurement (1983) studied different probing forces used by dental care
differed by > 3 mm. Depth of the pocket and location of providers based on levels of expertise (periodontists, gen-
the probing site did not influence the measurements. Van eral dentists, hygienists, and students). Probing forces ranged
der Velden and de Vries (1980), in a study involving 102 from 5 to 135 grams with no significant differences between
interproximal pockets in 7 periodontal patients, found no any of the examiner groups, although periodontists and hy-
differences in reproducibility of measurements between a gienists tended to probe with less force than general dentists
pressure-sensitive probe set at 0.75N and a Merritt B probe. and students. Probing force was found to be significantly
Aeppli et al. (1985) examined inter- and intraexaminer re- greater in posterior segments than in anterior segments. In
Section 1. Periodontal Probing CHAPTER 3. EXAMINATION AND DIAGNOSIS 37

addition to large interexaminer differences, intraexaminer var- untreated teeth, the probe tip penetrated beyond the apical
iability was also large, with a mean range of 44 grams. termination of the JE and into subjacent connective tissue
by a mean of 0.45 mm, whereas in the treated specimens
PROBE ANGULATION the probe tip stopped coronally to this landmark by a mean
Persson (1991) compared line-angle measurements to of 0.74 mm. These findings are in approximate agreement
midproximal measurements in untreated sites and found with earlier work (Magnusson and Listgarten, 1980) which
that the mean probing measurement was 1 mm greater with reported 1.4 mm in probing attachment gain in treated sites.
midproximal measurements than with line-angle measure- Anderson et al. (1991) correlated the degree of clinical
ments. This implies that clinical and epidemiological studies and histologic inflammation to probe tip penetration in
using line-angle measurements may underestimate pocket dogs. A significant correlation was noted between probe tip
depth and the true level of disease. penetration and amount of tissue inflammation adjacent to
The gingival sulcus is histologically or anatomically de- the probe. Correlations between gingival index and histo-
fined as the distance from the gingival margin to the coronal logic inflammation and gingival index and, probe penetration
end of the junctional epithelium to the coronal end of the were not significant. This suggests that probe penetration is
junctional epithelium (JE) (Listgarten, 1972). However, the more highly influenced by inflammation at the base of the
ability of the periodontal probe to accurately measure this pocket rather than marginal inflammation.
distance has been questioned by several studies in which
the position of the probe tip was evaluated in healthy and
LOCAL ANATOMY
diseased tissues. In a study of beagle dogs, Armitage et al.
Crown contours, interproximal versus facial or lingual
(1977) found that the probe failed to reach the apical ter-
sites, narrow pockets, tipped or rotated teeth, heavy osseous
mination of the JE in healthy specimens, but extended be-
ledges, and defective restorations and margins can affect
yond the most apical cells of the junctional epithelium in
probing accuracy. Moriarty et al. (1989) studied the vertical
periodontal specimens. Human studies such as that by Siv-
histologic probe position in untreated facial molar furcation
ertsen and Burgett (1976) indicated that the periodontal
sites. When vertical probing was carried out at the mid-
probe routinely penetrated to the coronal level of the con-
facial area of Class II and III furcations, the probe tip pen-
nective tissue attachment of untreated periodontal pockets.
etrated into interradicular connective tissue. The probe tip
Listgarten et al. (1976) observed that the most common
did not approximate tissue at the base of the pocket, but
position of the probe tip during routine measurements of
penetrated at various levels along the pocket wall. The au-
periodontal pocket depth was at the coronal portion of the
thors suggest probing the root surface anterior to and pos-
JE. Saglie et al. (1975) noted that probing depths measured
terior to the furcation entrance to more accurately reflect
in the laboratory were always less deep than those recorded
the true pocket depths at furcations.
clinically. The authors attributed this to the presence of a
zone of completely and partially destructed periodontal fi-
bers which allowed the probe to extend apically to the cor- TYPE OF PROBE USED
onal level of connective tissue attachment. These studies There are numerous types of probes with varying di-
have shown that periodontal probes do not precisely meas- ameters. Some examples are: Michigan, Williams, Marquis
ure and often overestimate the true histologic sulcus, and (round probes); and Goldman-Fox, Dellich, and Nabers (flat
that inflammation has a significant influence on the degree probes). Errors in manufacturing of the probes can signif-
of probe penetration. icantly affect measurements in clinical research settings.
Van der Zee et al. (1991) evaluated the accuracy of probe
STATUS OF GINGIVAL HEALTH markings in a variety of probes, noting that few probes
Glavind and Loe (1967) observed that non-standardized coincided with the manufacturer’s designated calibration.
forces in healthy tissue resulted in variations in probing The tip diameters ranged from 0.28 mm for the Michigan
depths of 1 mm compared to variations of over 2 mm in "O" probe to 0.7 mm for Williams’ probes. The widths of
inflamed tissue. Robinson and Vitek (1979) showed a probe markings were important in that painted bands dif-
straight line correlation between GI scores and tissue pen- fered by as much as 0.7 mm. Etched bands had the most
etration by the probe. Spray et al. (1978) suggested that the accurate width markings while etched grooves were nearly
state of health of the underlying CT fibers influenced prob- twice as inaccurate. Atassi et al. (1992) compared a paral-
ing measurements, with the healthy fibers acting as a barrier lel-sided probe to a tapered probe. The parallel-sided probe
and preventing apical movement of the instrument (the tended to yield deeper probing depths in deeper pockets
"hammock" effect). Caton et al. (1981) reported that in- suggesting that the tapered probe may tend to bind more
flamed CT offered less resistance to penetration and that within the pocket. However, the repeatability was similar
with reduction of inflammation following initial therapy, a for the tapered (81%) and parallel-sided (86%) probes. In
more accurate estimate of the sulcus depth resulted. Fowler addition, when the probe measurements were compared,
et al. (1982) showed through histologic examination that in 89% showed no difference in probing measurement.
38 CHAPTER 3. EXAMINATION AND DIAGNOSIS Section 1. Periodontal Probing

STRENGTH OF THE EPITHELIAL ATTACHMENT plaque-free sites were lower than for plaque-containing ar-
It is accepted that the probe cannot penetrate to the CT eas and did not differ among the recall groups. Lingual
without damaging the epithelial attachment. However, the surfaces had lower CPD values than other surfaces, and
strength of the epithelial attachment and its ability to resist molar areas had higher CPD values than non-molar teeth.
the probe is not known (De Waal et al., 1986). Another factor affecting the CPD may be the surrounding
environment of the tooth. Leveling is a theory suggesting
RELATIONSHIP BETWEEN PROBING AND BONE that a physiologic response takes place to maintain the same
LEVEL MEASUREMENTS level of anatomical attachment throughout a given area.
Isidor et al. (1984) evaluated transgingival probing When healthy areas which are adjacent to pathologically
measurements taken just prior to surgery and compared deepened sites are disturbed, one may see leveling, or the
them to measurements taken immediately after flap reflec- loss of attachment in the "healthy" sites and gain of at-
tion, utilizing a flexible stent to control probe angulation. tachment in the deepened sites.
Transgingival probing was identical to surgical measure-
ments 60% of the time and within 1 mm of surgical meas- REFERENCES
urements 90% of the time. Disagreement was never greater Aeppli D, Boen J, Bandt C. Measuring and interpreting increases in prob-
than 3 mm. Ursell (1989) studied the accuracy of probing ing depth and attachment loss. J Periodontal 1985;56:262-264.
with 30g or 60g force and vertical transgingival probing (> Akesson L, Hakansson J, Rohlin M. Comparison of panoramic and in-
lOOg force) as an estimate of open bone level measure- traoral radiography and pocket probing for the measurement of the
marginal bone level. J Clin Periodontol 1992;19:326-332.
ments. Higher correlations were found with transgingival The American Academy of Periodontology. Proceedings of the World
probing (r = 0.98) compared to measurements made at 30g Workshop in Clinical Periodontology Chicago: The American Acad-
(r = 0.87) and 60g (r = 0.90). A mean difference between emy of Periodontology; 1989.
measurements of 0.12 mm was found between transgingival Anderson GB, Caffesse RG, Nasjleti CE, Smith BA. Correlation of peri-
probing and surgical measurements. Agreement between odontal probe penetration and degree of inflammation. Am J Dent
1991;4:177-183.
transgingival probing and surgical measurements was un- Armitage GC, Svanberg GK, Loe H. Microscopic evaluation of clinical
affected by tooth type, tooth surface, inflammation, or mag- measurements of connective tissue attachment level. J Clin Periodon-
nitude of bone loss. Correlations were higher for 30g and tol 1977;4:173-190.
60g measurements when inflammation was present. When Atassi F, Newman HN, Bulman JS. Probe tine diameter and probing depth.
sites with intrabony defects were considered, the correlation J Clin Periodontol 1992;19:301-304.
Caton J, Greenstein G, Poison A. Depth of periodontal probe penetration
between transgingival probing and surgical measurements related to clinical and histologic signs of gingival inflammation. J Per-
was r = 0.79 and the mean difference between measure- iodontol 1981;52:626-629.
ments was 0.92 mm. Akesson et al. (1992) compared es- Chamberlain ADH, Renvert S, Garrett S, Nilveus R, Egelberg J. Signifi-
timation of bone levels with bone sounding and periapical, cance of probing force for evaluation of healing following periodontal
bite-wing, and panoramic radiographs to open measure- therapy. J Clin Periodontol 1985;12:306-311.
De Waal H, Kon S, Ruben M. Periodontal probing. J West Soc Perio-
ments. Bone sounding provided the best estimate of open dontol Periodont Abstr 1986;34:5-10.
bone level measurements. The percent underestimation was Fowler CT, Garrett S, Crigger M, Egelberg J. Histologic probe position
5% for bone sounding, 13% (maxillary) to 14% (mandib- in treated and untreated human periodontal tissues. J Clin Periodontol
ular) for periapicals, 17% (maxillary) to 23% (mandibular) 1982;9:373-385.
for bite-wings and 18% (maxillary) to 24% (mandibular) Freed HK, Capper RL, Kalkwarf KL. Evaluation of periodontal probing
forces. J Periodontol 1983;54:488-^92.
for panoramic radiographs. Percent image magnification Glavind L, Loe H. Errors in the clinical assessment of periodontol destruc-
was generally greater in the maxilla and was 8% for per- tion. J Periodont Res 1967;2:180-184.
iapical films, 9% for bite-wings, and 25% for panoramic Isidor F, Karring T, Attstrom R. Reproducibility of pocket depth and at-
radiographs. tachment level measurements when using a flexible splint. J Clin Per-
iodontol 1984;ll:662-668.
Jeffcoat MK, Jeffcoat RL, Jens SC, et al. A new periodontal probe with
CRITICAL PROBING DEPTH automated cemento-enamel junction detection. J Clin Periodontol
Lindhe et al. (1982) described the concept of critical 1986; 13:276-280.
probing depth (CPD), above which the result is gain of Lindhe J, Socransky S, Nyman S, Haffajee A, Westfelt E. "Critical probing
clinical attachment and below which a loss may occur. This depths" in periodontal therapy. J Clin Periodontol 1982;9:323-336.
Listgarten MA. Normal development, structure, physiology and repair of
CPD was shown to vary depending on the type of therapy gingival epithelium. Oral Sci Rev 1972;l:3-67.
used, with scaling and root planing having a CPD of 2.9 Listgarten MA. Periodontal terminology (Letters to the Editor). J Perio-
mm and modified Widman flap surgery having a CPD of dontol 1993;64:918.
4.2 mm. Westfelt et al. (1983) evaluated the significance of Listgarten M, Mao R, Robinson PJ. Periodontal probing and the relation-
frequently repeated recall appointments on CPD in 24 pa- ship of the probe tip to periodontal tissues. J Periodontol 1976;47:
511-513.
tients following modified Widman surgery. The CPD val- Magnusson I, Clark WB, Marks RG, Gibbs CH, Manouchehr-Pour M,
ues after 6 months of maintenance every 2, 4, or 12 weeks Low SB. Attachment level measurements with a constant force elec-
were 4.4, 4.9, and 5.4 mm respectively. CPD values for tronic probe. J Clin Periodontol 1988;15:185-188.
Section 2. Tooth Mobility CHAPTERS. EXAMINATION AND DIAGNOSIS 39

Magnusson I, Listgarten MA. Histologic evaluation of probing depth fol- direction and/or vertical depression or rotation of the crown
lowing periodontal treatment. J Clin Periodontol 1980;7:26-31. in its socket.
Mombelli A, Muhle T, Frigg R. Depth-force patterns of periodontal prob-
ing. J Clin Periodontol 1992;19:295-300. Instruments that have been used to measure and study
Moriarty J, Hutchens L, Scheitler L. Histological evaluation of periodontal tooth mobility include the macroperiodontometer, micro-
probe penetration in untreated facial molar furcations. J Clin Perio- periodontometer, and the Periotest. The macroperiodonto-
dontol 1989; 16:21-26. meter was developed by Muhlemann (1954); however, its
Persson G. Effects of line-angle versus midproximal periodontal probing
application was limited to the anterior teetn and premolars.
measurements on prevalence estimates of periodontal disease. J Per-
iodontRes 1991;26:527-529. The microperiodontometer was developed by O’Leary
Robinson PJ, Vitek RM. The relationship between gingival inflammation and Rudd (1963) and proved to be useful in measuring
and resistance to probe penetration. JPeriodont Res 1979;14:239-243. mobility in all of the teeth. Due to the time required to
Saglie R, Johansen JR, Flotra L. The zone of completely and partially obtain mobility measurements with these instruments, use
destructed periodontal fibers in pathological pockets. J Clin Periodon- was essentially limited to research.
tol 1975;2:198-202.
Sivertsen JF, Burgett FG. Probing of pockets related to the attachment
More recently, the Periotest has provided an objective
level. J Periodontol 1976;47:281-286. means of assessing tooth mobility. The instrument is com-
Spray JR, Garnick JJ, Doles LR, Kalwitter JJ. Microscopic demonstration pact, resembling a dental handpiece, and has an electro-
of the position of periodontal probes. J Periodontol 1978;48:148-153. magnetically retracting tapping head. The tapping head has
Ursell J. Relationships between alveolar bone levels measured at surgery,
a preset constant speed of 0.2 meters per second, and the
estimated by transgingival probing and clinical attachment level meas-
urements. J Clin Periodontol 1989;16:81-86.
contact time with the tooth varies from 0.3 to 0.2 millisec-
Van der Velden U. Probing force and the relationship of the probe tip to onds. Contact time upon impact is less in teeth whose
the periodontal tissues. J Clin Periodontol 1979;6:106-114. damping by the periodontium is greater (more support), and
Van der Velden U. Influence of probing force on the reproducibility of is therefore less mobile. A strong association between the
bleeding tendency measurements. J Clin Periodontol 1980;7:421-427.
Periotest value and bone loss has been reported (Shulte et
Van der Velden U, de Vries JH. Introduction of a new periodontal probe:
The pressure probe. J Clin Periodontol 1978;5:188-197. al., 1992). The Periotest has also been suggested as a means
Van der Velden U, de Vries JH. Influence of probing force on the repro- of objectively quantifying bone apposition around dental
ducibility of the depth measurements. J Clin Periodontol 1980;7:414- implants (Teerlinck et al., 1991).
420.
Van der Zee E, Davies E, Newman H. Marking width, calibration from
tip and tine diameter of periodontal probes. J Clin Periodontol 1991; DYNAMICS OF TOOTH MOBILITY
18:516-520. The periodontal ligament (PDL) surrounds the roots of
Westfelt E, Nyman S, Socransky S, Lindhe J. Significance of frequency the teeth and acts as a shock absorber to some extent. Col-
of professional tooth cleaning for healing following periodontal sur- lagen fibers constitute 50% to 75% of the PDL volume with
gery. J Clin Periodontol 1983;10:148-156.
the oblique fibers predominating (Weatherford, 1977).
Tooth mobility seems to occur in two stages (See Weath-
erford, 1977, for review). First, there is an initial or intra-
vascular stage where movement within the socket is
associated with redistribution of the fluids, interstitial con-
tents, and fibers. The second stage occurs gradually and
Section 2. Tooth Mobility
includes elastic deformation of the alveolar bone proper in
response to increased forces (Muhlemann, 1967).
DEFINITIONS
Fremitis: A palpable or visible movement of a tooth TYPES OF MOBILITY
when subjected to occlusal forces. Physiologic mobility is movement that occurs with nor-
Tooth Mobility: The degree of looseness of a tooth be- mal function (100 to 150g). It will vary from tooth-to-tooth
yond physiologic movement. and day-to-day and has been defined as movement up to
0.2 mm horizontally and 0.02 mm axially (Weatherford,
MEASUREMENT OF TOOTH MOBILITY 1977).
The most commonly used clinical index for mobility is Pathologic mobility may be 10-fold that of "physiologic
the Miller Index (Miller, 1950). Mobility is detected by mobility" and is associated with damage to the PDL ini-
using an instrument (e.g., mirror handle) on either side of tiated by injury to the collagen fibers and associated loss
the tooth and applying force. Using this index, mobility is of osseous support. Fremitus is a palpable or visible move-
scored as follows: ment of a tooth when subjected to occlusal forces. Perlitsh
1 = first distinguishable sign of movement greater (1980) described a "critical mass" of alveolar bone sup-
than "normal;" port. He speculates that if < 50% of the total root length
2 = movement of the crown up to 1 mm in any di- remains surrounded by alveolar bone, zones of injury from
rection; and excessive occlusal forces are irreversible and may involve
3 = movement of the crown more than 1 mm in any the entire PDL space. Conversely, alveolar bone support
40 CHAPTER 3. EXAMINATION AND DIAGNOSIS Section 3. Radiographic Interpretation

greater than the "critical mass" provides healthy tissue for ever, as the amount of bone loss increases and the support
repair and changes are reversible. The critical mass for mo- decreases, the significance of the support offered by the
lars is located more coronal due to the complications of the supracrestal fibers increases.
furcations. This is an interesting concept and may be use-
ful in assessing the prognosis of periodontally affected REFERENCES
teeth. Ericsson I, Lindhe J. Lack of significance of increased tooth mobility in
experimental periodontitis. J Periodontol 1984;55:447-552.
Fleszar T, Knowles JW, Morrison EC, et al. Tooth mobility and perio-
CLINICAL IMPLICATIONS OF TOOTH MOBILITY dontal therapy. J Clin Periodontol 1980;7:495-505.
Ericsson and Lindhe (1984) subjected dogs to excessive Gillespie B, Chasens A. The relationship between the mobility of human
teeth and their supracrestal fiber support. J Periodontol 1979;50:120-
jiggling forces (healthy periodontium) and found increased 124.
mobility due to loss of bone volume but no loss of CT Kerry G, et al. Effect of periodontal treatment on tooth mobility. J Per-
attachment (physiologic adaptation). When an experimental iodontol 1982;53:635-638.
periodontitis was initiated, no additional loss of attachment Miller SC. Textbook of Periodontia, 3rd ed. Philadelphia: Blackston; 1950:
was seen compared to control sides. The authors concluded 125.
Muhlemann H. Tooth mobility. I. The measuring method. Initial and sec-
that the permanently increased mobility had no influence ondary tooth mobility. J Periodontol 1954;25:22-29.
on the development of periodontitis. Muhlemann H, Rateitschak KH. Quantitative evaluation of the therapeutic
Perrier and Poison (1982) induced an experimental per- effect of selective grinding. J Periodontol 1957:28:11-16.
iodontitis in squirrel monkeys; 10 weeks later, jiggling Muhlemann H. Tooth mobility: A review of clinical aspects and research
trauma was imposed for 10 weeks in the presence of good findings. J Periodontol 1967;38:386.
O’Leary TJ, Rudd KD. An instrument for measuring horizontal tooth mo-
plaque control. Results showed that occlusal trauma in a bility. Periodontics 1963;l:249-254.
reduced periodontium caused no additional attachment loss Perlitsh M. A systematic approach to the interpretation of tooth mobility
or bone height loss if inflammation was controlled by ef- and its clinical implications. Dent Clinics N Am 1980;24:177-193.
fective plaque control. However, additional loss of bone Perrier M, Poison A. The effect of progressive and increasing tooth hy-
volume was seen. permobility on reduced by healthy periodontal supporting tissue. J
Periodontol 1982;53:152-157.
Fleszar et al. (1980) examined the relationship between
Schulte W, d’Hoedt B, Lukas D, Maunz M, Steepler M. Periotest for
tooth mobility and clinical responses to periodontal therapy measuring periodontal characteristics. Correlation with periodontal
in the Michigan longitudinal studies. The authors reported bone loss. J Periodont Res 1992;27:184-190.
that shallow sites lost attachment over time but that initially Teerlinck J, Quirynen M, Darius P, Steenberge DV. Periotest: An objec-
mobile teeth tended to lose more attachment. The 4 to 6 tive clinical diagnosis of bone apposition toward implants. Int J Oral
Maxillofac Implants 1991;6:55-61.
mm sites that were non-mobile initially gained attachment
Weatherford T. Tooth mobility: Mechanisms and treatment. Ala J Med
while the 4 to 6 mm sites with 2 and 3 degrees mobility Sci 1977; 14:32-38.
lost some attachment by the second year. All teeth with
deep pockets (7 to 12 mm) gained attachment following
treatment but mobile teeth (2 and 3 degrees mobility) did
not gain attachment.
Kerry et al. (1982) examined changes in mobility over
time after 4 modes of periodontal therapy. The authors
Section 3. Radiographic
found that abnormal mobilities tended to decrease follow- Interpretation
ing the hygienic phase of therapy. Modified Widman flap
therapy, scaling and root planing, and curettage had no in- Limitations of Radiographs
fluence on further mobility while pocket elimination ther- Radiographs do not: 1) show periodontal pockets; 2) dis-
apy increased mobility after surgery, decreasing to tinguish between successfully treated and untreated cases;
presurgical levels after 1 year. 3) record morphology of bony defects; 4) show structures
Muhlemann and Rateitschak (1957) examined changes on buccal, lingual, and labial aspects of tooth; 5) show soft-
in mobility patterns following selective grinding. Teeth in to-hard tissue relationships; or 6) record tooth mobility
hypofunction were 30% more mobile than those in hyper- (Prichard, 1983).
function. Teeth in hypofunction had a decreased width of
the PDL; the fibers become less well-arranged and are BENEFITS OF RADIOGRAPHS
aligned more parallel to the root (non-functional arrange- Radiographs effectively accomplish the following: 1)
ment). After selective grinding, teeth in both hypofunction record (with correct technique) position of septal bone on
and hyperfunction became less mobile; these observations the tooth in one plane; 2) serve as an adjunct to the clinical
were interpreted by the authors as improvement in perio- exam but cannot offer conclusive evidence alone; 3) record
dontal health. the alveolar bone, alveolar process, and PDL on mesial,
Gillespie and Chasens (1979) showed that supracrestal distal, and apical aspects of the root in a single plane; 4)
fibers do not provide support for a healthy premolar; how- document clinical-crown-to-clinical-root ratio; and 5) allow
Section 3. Radiographic Interpretation CHAPTER 3. EXAMINATION AND DIAGNOSIS 41

observation of dense deposits of calculus and metallic re- junctions, they were visible. If the inner surface of the cor-
storative margins on proximal tooth surfaces (Prichard, tex was eroded further, the area became even more dis-
1983). cernible. Ramadan and Mitchell (1962) reported that: 1)
minor destructive changes in the alveolar crest could not be
INTREPRETATION OF RADIOGRAPHS detected by x-ray; 2) destruction of the buccal plate could
not be distinguished from destruction of the lingual plate;
Interdental Septa 3) funnel-shaped defects with intact buccal and lingual
In the absence of periodontal disease, the configurations plates could not be detected; 4) the long-cone paralleling
of the crests of the interdental septa are determined by rel- technique is the most reliable for obtaining acceptable im-
ative positions of the cemento-enamel junction (CEJ). ages; 5) removal of the entire buccal and lingual plate did
When periodontal disease is present, alterations in inter- not affect the trabecular pattern; 6) bone destruction caused
dental septa are governed principally by specific pathologic by abscesses is not seen if it is superimposed by roots; and
processes. The shape and size of crowns of the teeth, state 7) both junctional and central core of trabecular bone must
of eruption, and position of teeth can influence septal con- be removed to affect radiographic architecture.
tour. If approximating tooth surfaces are relatively flat, Rees et al. (1971) examined the radiographic appearance
septa will be more narrow and pointed. If mesial and distal of alveolar osseous defects in dry skulls to determine the
tooth surfaces are extremely convex, interdental septa will predictability of diagnosing the defects on the basis of ra-
be wide with flat crests. The greater the buccal-lingual di- diographic appearance. They found that proximal osseous
mension of the teeth, the greater the width of the interdental defects and furcation defects on the facial and lingual sur-
bone. If there is a difference in length of the crowns of faces of multi-rooted teeth can be identified with a high
adjoining teeth whose occlusal surfaces are in the same degree of accuracy based on their radiographic appearances.
plane, the crest will slant upward from the CEJ of the long Conversely, lesions on the facial or lingual root surfaces
crown toward the CEJ of the short crown. Any inclination are extremely difficult to recognize radiographically. These
of long axis of the teeth results in a difference in the levels studies indicate that although radiographs are valuable ad-
of the mesial and distal CEJs and produces oblique alveolar juncts, clinical and radiographic findings must be correlated
crests. Assuming mesial and distal contacts between the in order to facilitate a correct diagnosis.
teeth, there is no correlation between occlusal disharmonies
and the radiographic appearance of the crests (Ritchey and Periodontal Ligament (PDL)
Orban, 1953). Using an artificial model, Van der Linden and Van Aken
(1970) reported that the same width of the PDL can be
Lamina Dura interpreted as being different when the radius of circum-
Using 17 autopsy specimens, Manson (1963) found that ference is different, exposure time is changed, or when kil-
the appearance of the lamina dura is determined as much ovoltage is changed. The number of PDL projections
by shape and position of the tooth root in relation to the x- depends upon the width and depth of root concavity and
ray beam as by the integrity of this plate of bone. Using the thickness of the PDL projections depends upon the
microradiographs, he also noted that the bone comprising width and depth of root concavity and the thickness of the
the socket wall (cribriform plate) has the same mineral con- PDL, as well as horizontal angulation of the x-ray beam.
tent as adjacent bone. The author was able to produce a The marginal aspect of the PDL in the radiograph varies
pseudo-lamina dura as an artifact and concluded that critical significantly with the horizontal angulation of the x-ray
interpretation of the integrity of the lamina dura should be beam and may lead to a subjective widening or complete
avoided. Greenstein et al. (1981) studied the relationship of loss of the PDL.
the crestal lamina dura to clinical parameters in 90 subjects.
They reported no correlation between clinical parameters of Healing
bleeding pockets or attachment loss and the presence or In periodontitis, increased radiolucency and cupped-out
absence of crestal lamina dura. The authors recommended appearance of alveolar crests are noted on the radiograph.
caution when using the integrity of the crestal lamina dura The cortical layer has been destroyed and underlying mar-
as an indicator for diagnosis of periodontal disease and pre- row spaces have been exposed and enlarged, decreasing the
dictor of therapeutic needs. density. After treatment, the marrow spaces become smaller
and new cortical bone is laid down, increasing the density.
Osseous Defects This increased density can lead to the misinterpretation of
Bender and Seltzer (1961), using human mandibles ob- coronal bone regeneration when, in reality, it is only an
tained at autopsy, compared artificially-created periodontal increase in quality of bone (Friedman, 1958).
and periapical lesions clinically and radiographically. They Normal level of crestal alveolar bone: Hausman et al.
reported that lesions could not be observed on radiographs (1991) evaluated 13- to 14-year-old children to determine
as long as they were confined in cancellous structures. the average distance of the CEJ to alveolar bone. They
However, if lesions encroached on the cancellous-cortical found the average distance was 0.4 to 1.9 mm (mean 1.1
42 CHAPTER 3. EXAMINATION AND DIAGNOSIS Section 3. Radiographic Interpretation

mm) and suggested that this distance increases with age as ficult to distinguish from gray level variations due to actual
a result of continuous eruption. Goodson et al. (1984) ex- bone changes. This has been a major disadvantage of the
amined the relationship between changes detected on radi- technique to this point (Hausmann et al., 1985). In a review
ographs and changes in clinical attachment levels using of radiographic techniques for clinical trials, Reddy (1992)
standardized radiographs. They examined 231 sites and ob- noted that subtraction radiography gives precise informa-
served that clinical attachment loss precedes visual radio- tion, the technique is time consuming and labor intensive,
graphic changes by 6 to 8 months and, in all cases, clinical and advances have been made in subtraction radiography
attachment changes were greater than observed radio- with the digitalization of images.
graphic changes. Radiographic change was not always de-
tected in sites exhibiting clinical attachment change. The
DIGITAL IMAGING
authors stated that radiographic changes may have been de-
New computer and video technology has led to the de-
tected sooner if subtracted images had been used.
velopment of digital subtraction radiography (DSR). Light
intensity transmitted through a radiograph is measured at
XERORADIOGRAPHY each picture element (pixel) by a video camera and con-
Xeroradiography is a diagnostic x-ray imaging system verted into gray-level values. The digitized image is stored
which uses the xerographic copying process to record x-ray on a computer and displayed on a TV screen as a positive
images. Xeroradiographic images (XIs) differ from conven- image. A subsequent radiograph is displayed as a negative
tional images, having greater exposure, latitude, and a image on the screen and aligned to the structures of the
property termed "edge enhancement" by which fine struc- baseline image revealing differences in density between
tures (bone, trabeculae, etc.) and areas of subtle density baseline and subsequent radiographs. Numerous studies us-
differences (gingiva, etc.) are visually enhanced. Conven- ing artificially-created bone defects in dry skulls, cadavers,
tional dental x-ray units can be used to produce high-quality and animals have determined the diagnostic accuracy of
dental XIs at significantly reduced radiation levels. In a DSR (Braegger, 1988A, 1988B). Few studies have dealt
human study with 96 patients, similar x-ray projections with the naturally-occurring lesion. Hausmann et al. (1986)
were made with conventional film and experimental dental were able to demonstrate bone changes in 9% of sites in 9
xeroradiographs. Resultant images were compared visually of 15 patients with untreated periodontitis over 6 months
and, in all categories (gingival soft tissues, calculus depos- using DSR. Braegger (1988A, 1988B) found that bone den-
its, osseous tissues), information provided by XIs was equal sity changes assessed with computer-assisted densitometric
to or greater than conventional radiographs. The authors image analysis (CADIA) correlated well with actual cal-
found dental xeroradiographs to be a highly accurate, low cium loss. Braegger et al. (1987) also detected surgically-
in radiation, rapid, and convenient alternative to conven- induced bone loss (crown lengthening or flap osteoplasty)
tional intra-oral radiography. There have been, however, with a sensitivity of 82% and specificity of 88% by means
numerous technical difficulties with the processing equip- of CADIA. DSR (i.e., CADIA) enables smaller changes in
ment which have limited its use (Graft et al., 1980). alveolar bone density, undetectable by conventional radi-
ography, to be detected and quantified. Deas et al. (1991)
SUBTRACTION RADIOGRAPHY used CADIA to determine if changes in bone density could
Subtraction radiography is a technique which uses com- be an indicator of progression of periodontitis; 38.3% of
puter-assisted imaging to convert different densities re- the sites investigated lost radiographic density and only
corded on a conventional x-ray film into digitized gray level 6.1% of sites showed loss of attachment. The authors sug-
images. The gray level images of a second film are super- gested there was a complex relationship between loss of
imposed over the first and differences subtracted. Two iden- attachment and changing bone densities and that progres-
tical films would result in all gray levels being subtracted, sion of disease cannot be based solely on loss of bone den-
leaving a blank image. Differences in bone density over sity.
time (gain or loss) would be recorded as different digitized
gray levels with subtracted images reflecting gains or losses
of density. The rationale for its use is based on the fact REFERENCES
Bender IB, Selzer D. Roentgenographic and direct observation of exper-
with conventional radiographs, more than 30% of the bone imental lesions in bone. J Am Dent Assoc 1961;62:152-160.
mass at the alveolar crest has to be lost (or gained) before Braegger U, Litch J, Pasquali L, et al. Computer assisted densitometric
it can be recognized. Subtraction radiography can detect image analysis for quantitation of radiographic alveolar bone changes.
changes in bone density as small as 5%. The sensitivity of JPeriodont Res 1987;22:227.
Braegger U. Digital imaging in periodontal radiography. J Clin Periodon-
subtraction to accurately detect changes in bone depends on
tol 1988A;15:551-557.
radiographs with standardized geometry, allowing precise Braegger U, Pasquali L, Rylander H, et al. Computer-assisted densito-
super-imposition. If the radiographic images cannot be com- metric image analysis in periodontal radiography. J Clin Periodontol
pletely aligned, areas of differing gray levels (structured 1988B; 15:27.
noise) may appear on the subtracted image, making it dif- Deas D, Pasquali L, Yuan C, Kornman K. The relationship between prob-
Section 4. Mucogingival Considerations CHAPTER 3. EXAMINATION AND DIAGNOSIS 43

ing attachment loss and computerized radiographic analysis in moni- tissue of 2 mm (with at least 1 mm being attached) is ad-
toring progression of periodontitis. J Periodontol 1991;66:135-141.
equate to maintain gingival health.
Friedman N. Reattachment and roentgenograms. J Periodontol 1958;29:
98-111. Other studies, however, have not supported routine
Goodson JM, Haffajee AD, Socransky S. The relationship between at- grafting of sites with minimal or no keratinized or attached
tachment level loss and alveolar bone loss. J Clin Periodontol 1984; gingiva. Ten unilateral and 6 contralateral study pairs of
11:348-359. premolar teeth, each with one tooth having minimal kera-
Graft BM, Sickles EA, Armitage GC. Use of dental xeroradiographs in
tinized gingiva < 1 mm with no attached gingiva and the
periodontics. Comparison with conventional radiographs. J Periodon-
tol 1980;51:1^. other having appreciable keratinized tissue (> 2 mm) were
Greenstein G, Poison A, Iker H, Meitner S. Associations between crestal evaluated for gingival health (Miyasato et al., 1977). The
lamina dura and periodontal status. J Periodontol 1981;52:362-366. 6 contralateral study pairs were observed over a 25-day
Hausmann E, Dunford R, Wikesjo U, Christersson L. Assessment of the period of experimental gingivitis (no oral hygiene). Sites
progression of untreated periodontitis by subtraction radiography. J
with plaque or high frenum insertions were excluded from
PeriodontRes 1986;21:716-722.
Hausmann E, Christersson L, Dunford R, et al. Usefulness of subtractive the study. No differences in gingival health were observed
radiography in the evaluation of periodontal therapy. J Periodontol between sites with or without keratinized tissue. In addition,
1985;56(Suppl.):4-7. sites with minimal keratinized gingiva and no attached gin-
Hausmann E, Allen K, Clevhugh V. What alveolar bone level on a bite- giva were no more prone to develop plaque-induced inflam-
wing radiograph represents bone loss? J Periodontol 1991;62:570-
matory changes than areas with attached gingiva and a
572.
Manson JD. Lamina dura. Oral Surg Oral Med Oral Pathol 1963;16:432- greater zone of keratinized tissue.
438. Using beagle dogs, Wennstrom and Lindhe (1983) stud-
Prichard J. Interpretation of radiographs in periodontics. Int J Periodontics ied the effect of plaque at sites with or without attached
Restorative Dent 1983j3:8-39. gingiva and with varying heights of the attachment appa-
Ramadan A, Mitchell DF. Roentgenographic study of experimental bone
ratus, over a 40-day period of experimental gingivitis (no
destruction. Oral Surg Oral Med Oral Pathol 1962; 15:934-943.
Reddy M. Radiographic methods in the evaluation of periodontal therapy. oral hygiene). The results indicated that the inflammatory
J Periodontol 1992;63:1078-1084. response to bacterial plaque accumulation is unrelated to
Rees T, Biggs NL, Collins CK. Radiographic interpretation of periodontal the presence or absence of attached gingiva, or to the height
osseous defects. Oral Surg Oral Med Oral Pathol 1971;2:141-153. of the supporting attachment apparatus. The authors con-
Ritchey B, Orban B. The crests of the interdental alveolar septa. J Per-
cluded that a free gingival unit which is supported by
iodontol 1953;24:75-87.
Van der Linden L, Van Aken J. The periodontal ligament in the roent- loosely attached alveolar mucosa is no more susceptible to
genogram. J Periodontol 1970;41:243-248. an inflammation than a free gingival unit which is sup-
ported by a wide zone of attached gingiva.
In a 1983 human study, Wennstrom examined the clin-
ical response following the surgical removal of the entire
zone of attached gingiva. He reported that gingival reces-
sion occurred only during the first 3 post-operative months
Section 4. Mucogingival and remained stable over the next 6 months independent of
the presence or absence of attached gingiva or the width of
Considerations keratinized tissue. Regardless of the presence or absence of
The question of whether or not to treat areas diagnosed
attached gingiva, gingival units were without clinical signs
as having little or no attached gingiva has been a matter of
of inflammation over the 9-month period.
controversy in the past several years. Prior to the 1980s,
Kisch et al. (1986) studied canines and premolars with
preventive soft tissue grafting of areas with minimal at-
no attached gingiva and mobility of the gingival margin
tached gingiva was the accepted routine. This was
over a 5-year period. The mucogingival margin was iden-
prompted by such studies as that by Lang and Loe in 1972.
tified using Lugol’s iodine solution. They failed to dem-
Using Schiller’s stain to identify the mucogingival junction
onstrate that unattached and mobile facial gingival surfaces
in patients with optimal oral health, these authors reported
are more susceptible to periodontal breakdown than at-
a correlation between the width of keratinized tissue and
tached surfaces in subjects with good oral hygiene and clin-
attached gingiva and periodontal health. While over 80%
ically healthy gingiva.
of the surfaces with > 2 mm of keratinized tissue and >1
In a 5-year longitudinal study, Wennstrom (1987) con-
mm of attached gingiva were clinically healthy (76% had
firmed the observations from his 1983 studies. In patients
no gingival exudate), all surfaces with < 2 mm of keratin-
maintaining good oral hygiene, the lack of an "adequate"
ized gingiva and < 1 mm or more of attached gingiva ex-
zone of attached gingiva did not result in an increased in-
hibited clinical inflammation and varying amounts of
cidence of soft tissue recession. The author hypothesized
gingival exudate. These findings suggested that gingival in-
that a narrow zone of gingiva apical to a localized recession
flammation results at least in part from a movable gingival
is a consequence rather than a cause of the recession.
margin which facilitates the introduction of microorganisms
In another longitudinal study, Kennedy et al. (1985) ex-
into the sulcus. It was concluded that a width of keratinized
44 CHAPTER 3. EXAMINATION AND DIAGNOSIS Section 4. Mucogingival Considerations

amined 32 patients over a 6-year maintenance period who root surface with minimal keratinized tissue and no attached
had insufficient attached gingiva on one side and a free soft tissue; 3) labial incisor eruption with minimal keratinized
tissue graft on the other. In addition, 10 patients who had tissue, no attached gingiva, and no lingual movement of the
not maintained recall appointments were re-examined. Re- tooth is planned; 4) tooth eruption into a rotated position
sults indicated that both treated and untreated sites of all and minimal keratinized tissue; 5) thin periodontium and
patients remained stable over the 6-year period. It was con- labial tooth movement is planned; 6) root exposure during
cluded that the free gingival graft is a predictable means of orthodontic movement; 7) maxillary incisor overbite strip-
enhancing the zone of attached gingiva and, in time, results ping keratinized tissue on facial mandibular incisors. If or-
in creeping attachment. However, if plaque control is ade- thodontic treatment is anticipated, the authors felt
quate, minimal to zero attached gingiva can be maintained autogenous grafts should be placed prior to therapy when
in a state of health. It must be noted that control sites with mucogingival problems exist.
little or no attached gingiva in the unmaintained patients Tenenbaum and Tenenbaum (1986) studied the width of
had a 20% frequency of further recession (mean recession facial gingiva in subjects aged 3 to 15 years (using a jig-
= 0.5 mm). This suggests at least some risk of recession gling technique), noting that attached gingiva increases with
in sites with little attached gingiva, whereas no recession age in both the primary and permanent dentitions. How-
was noted on teeth with wide zones of attached gingiva. ever, contrary to the findings of Bowers (1963), they re-
A 10-year longitudinal study of sites with minimal ker- ported it does not increase as a result of the transition from
atinized gingiva (< 2 mm of keratinized, but > 1 mm of the primary to permanent dentition. Since sulcus depth de-
attached gingiva) in 18 dental students with good oral hy- creased with age, it was concluded that the increase in
giene, minimal inflammation, and no restorations in the area width of attached gingiva results from decreased sulcus
of observation was completed (Freedman et al., 1992). It was depth. Stated in another way, although sulcus depth de-
observed that the majority of sites remained unchanged or creases with age and results in increased attached gingiva,
had a slight increase in keratinized gingiva. It was concluded width of keratinized gingiva does not vary.
that in the absence of inflammation, areas with minimal ker- Andlin-Sobocki et al. (1991) completed a 3-year longi-
atinized gingiva remain stable over a long period of time. tudinal study of 28 six to 13-year olds who initially pre-
Mucogingival considerations in restorative dentistry sented with labial marginal recession associated with
were addressed in a 1987 study by Stetler and Bissada. permanent central incisors. Over the 3-year period, an over-
They compared the tissue response (GI) around teeth with all reduction in recession occurred with a gradual gain in
and without subgingival margins in association with narrow clinical attachment levels. Since gingival recession on the
(< 2 mm) or wide (> 2 mm) zones of keratinized gingiva. facial of mandibular incisors often decreases or is totally
Higher GI scores were observed when subgingival margins eliminated over time (in children), the authors suggested
of restorations were present in areas with a narrow zone of that surgical treatment to correct the recession should be
keratinized gingiva. The authors concluded that in the pres- postponed until possible spontaneous improvement has
ence of subgingival margins, a greater inflammatory gin- been allowed to occur.
gival response is associated with a narrow band of
keratinized gingiva, although no significant differences
were found in attachment levels or bone height. They in- REFERENCES
Andlin-Sobocki A, Marcusson A, Persson M. 3-year observations on gin-
dicated that if subgingival restorations were to be placed in gival recession in mandibular incisors in children. J Clin Periodontol
areas of minimal keratinized gingiva and less than optimal 1991;18:155-159.
plaque control, augmentation to widen the zone of keratin- Bowers GM. Study of the width of gingiva. J Periodontol 1963;34:201-
ized tissue may be warranted. It was also noted that in 209.
Freedman A, Salkin L, Stein M, Green K. A 10-year longitudinal study
unrestored teeth there was no significant difference in the
of untreated mucogingival defects. J Periodontol 1992;63:71-72.
inflammatory status of sites with or without a wide zone of Kennedy J, Bird W, Palcanis K, Dorfman H. A longitudinal evaluation of
keratinized tissue. varying widths of attached gingiva. J Clin Periodontol 1985;12:667.
Mucogingival problems in children were discussed by Kisch J, Badersten A, Egelberg J. Longitudinal observation of "unat-
Maynard and Wilson in a 1980 article. They indicated they tached," mobile gingival areas. J Clin Periodontol 1986;13:131-134.
Lang N, Loe H. The relationship between the width of keratinized gingiva
had never observed mucogingival problems in the decidu- and gingival health. J Periodontol 1972;43:623-627.
ous dentition unless created by a factitial injury. Mucogin- Maynard JG, Wilson R. Diagnosis and management of mucogingival
gival problems tend to originate in the mixed and early problems in children. Dent Clin N Am 1980;24:683-703.
permanent dentition resulting from developmental aberra- Miyasato M, Crigger M, Egelberg J. Gingival condition in areas of min-
tions in eruption and deficiencies in the thickness of the imal and appreciable width of keratinized gingiva. / Clin Periodontol
1977;4:200-209.
periodontium. The authors indicated the following muco-
Stetler KJ, Bissada NF. Significance of the width of keratinized gingiva
gingival problems may progress with age and should be on the periodontal status of teeth with submarginal restorations. J Per-
treated with an autogenous gingival graft: 1) marginal tissue iodontol 1987;58:696~700.
comprised of alveolar mucosa with frenum pull; 2) exposed Tenenbaum H, Tenenbaum M. A clinical study of the width of the at-
Section 4. Mucogingival Considerations CHAPTER 3. EXAMINATION AND DIAGNOSIS 45

tached gingiva in the deciduous, transitional and permanent dentitions. Wennstrom J. Regeneration of gingiva following surgical excision. A clin-
J Clin Periodontol 1986; 13:270-275. ical study. J Clin Periodontol 1983;10:287-297.
Wennstrom J, Lindhe H. Plaque-induced gingival inflammation in the ab- Wennstrom J. Lack of association between width of attached gingiva and
sence of attached gingiva in dogs. J Clin Periodontol 1983;10:266- development of soft tissue recession. A 5 year longitudinal study. J
276. Clin Periodontol 1987;14:181-184.