Periodontal Examination
Part-II
Dr. A. Al-Osman
Objectives :
• Recognize the clinical importance of periodontal probing
• Recognize the assessment of clinical attachment loss
Periodontal Probing
Periodontal probing:
• Two types of probing measurements are used:
‣ Probing Depth (PD)
‣ The following term, also, used to mean probing depth:
‣ Probing Pocket Depth (PPD)
‣ Clinical Attachment Level (CAL)
Important
• Probing untreated periodontal patients could induce a
bacteremia
• Occurred in 8 of 20 patient with periodontitis & 2 of 20 patients
with gingivitis (Daly, 1997) (Daly, 2001)
Probing Depth:
The distance from the soft tissue margin (gingiva or alveolar
mucosa) to the tip of the periodontal probe during usual periodontal
diagnostic probing
Glossary of Periodontal Terms. 4th edition ; 2001. The American Academy of Periodontology
Pockets can be classified as follows:
• Gingival pocket
• Periodontal pocket
Gingival Pocket/Pseudopocket:
A pathologically deepened gingival crevice
that does not involve loss of connective
tissue attachment. Frequently observed
when there is gingival enlargement
A- “SULCUS”: histologically, in healthy gingiva, the sulcus is maximally 0.5 mm
deep. However, upon probing, the probe may penetrate the junctional
epithelium
B & C “GINGIVAL POCKET”: in gingivitis, the coronal portion of junctional
epithelium detaches from the tooth. There is no true attachment loss. with
swelling of gingiva, gingival pocket (also called pseudopocket) may develop. In
addition to gingivitis, this may be seen in drug-induced gingival enlargement.
Note apical end of JE still at CEJ and the CT fibers if gingiva between CEJ and
the crest of alveolar bone remain intact
Periodontal Pocket:
A pathologic fissure between a tooth and the crevicular
epithelium, and limited at its apex by the junctional
epithelium
It is abnormal apical extension of the gingival crevice
caused by migration of the junctional epithelium along
the root as the connective tissue fibers of gingiva
(between CEJ and crest of alveolar bone) and
periodontal ligament are detached by disease process
Periodontal
pocket
Attachment loss
The clinical outcomes of the events at periodontium’s cellular and
molecular levels in periodontitis case are the formation of periodontal
pocket/attachment loss (A) and bone loss (B)
A
Periodontal pockets are sub-classified into:
• Suprabony (fig.A):
o In which the bottom of the pocket is coronal to the underlying
alveolar bone
• Intrabony (infrabony) (fig.B):
B
o In which the bottom of the pocket is apical to the level of the
adjacent alveolar bone
o The lateral pocket wall lies between the tooth surface and the
alveolar bone
Infrabony / intrabony defects:
A. One-wall infrabony defect
B. Two-wall infrabony defect
C. Three-wall intrabony defect
D. Interproximal crater
Adapted from: Papapanou & Tonetti-Periodontology 2000-2000 vol.22
Periodontal Probing
• Clinical example of infrabony pocket at the mesial of tooth
# 36. Note the vertical (angular) defect at the mesial of #36
(arrow)
Periodontal Probing
• Another clinical example of infrabony pocket at tooth # 44. Again,
note the type of bone loss
What would be the type of bone loss in the case of suprabony pocket?
Intra-bony Pocket
Probing Depth VS. Pocket Depth! (Listgarten, 1993)
• Probing Depth is a Clinical Term. (approximation)
• Pocket depth is a Histologic Term. (accurate)
Where does the tip of the probe stop during periodontal probing?
• In healthy periodontium, the probe tip usually will stop within the
junctional epithelium 0.2-0.4 mm coronal to the insertion of
connective insertion into the root (Caton 81, Polson 80)
• In inflamed pocket, the probe tip penetration often extends beyond
the apical end of the junctional epithelium 0.3mm or more into
connective tissue (Lisgarten,76; Bulthuis 98)
• This explains why clinical sulcus/pocket probing depth
measurement is an approximation. It is not an accurate
representation of the anatomic sulcus/packet (from gingival margin
to “base of sulcus/pocket”) which can only accurately determined
by histology
Periodontal probes with various millimeter indications. From right
to left:
• Goldman Fox with flat end: Recommended for sounding-to-bone
• UNC 15 (Hu Friedy): millimeter markings, and a wide, black marking at 5,
10 and 15mm
• GC-American: 3, 6, 9, 12
• CP12 (Hu-Friedy): 3, 6, 9, 12
• CPITN/WHO: 0.5(ball), 3.5, 5.5, 8.5, 11.5
Plastic probes:
• Sterilizable probes for probing depth measurements, mainly,
around dental implants
• From left-right:
‣ CPITN: 3, 6, 9, 12
‣ HU-FRIEDY: 3, 6, 9, 12
‣ HAWE: 3, 5, 7 10
‣ HAWE “Click Probe”: 3, 5, 7, 10
Probing Depth:
• Probing involves a gentle stepping of a calibrated
periodontal probe around the tooth and recording the
deepest point at:
o Distofacial
o Facial
o Mesiofacial
o Distolingual
o Lingual
o Mesiolingual
Probing Technique:
• The probe is inserted into the pocket and moved
apically along the root surface until “soft”
resistance from the tissues at the base of the
probeable pocket is encountered
• Care should be taken to probe under the
contact points from both facial and lingual
aspects, because the deep pockets frequently
develop in this location
• Fig. A: Periodontal probe inserted at the disto-
lingual line-angle of tooth # 16. PD measurement
is 4 mm A
• Fig.B: The periodontal probe is inserted correctly
under the contact on the disto-lingual of same
tooth (#16). PD is 8 mm B
BL: line-angle measurements may underestimate the PD and not represent the actual PD
under the contact point. Guide the probe under the contact point, particularly, in
premolars and molars areas
Factors Affecting Probing Depth Measurements:
• Presence of inflammation
‣ over-estimate PD.
• Presence of subgingival calculus
‣ under-estimate PD
• Probing force:
‣ Gentle probing force of around 0.25N (25 g) should be used
‣ Applying a probe to a fingernail, a 25g force will initiate blanching of the
‣
nail bed (Greenstein, 1990)
Excessive probing force yields overestimated measurement
• Probe tip diameter
• Patient comfort and tolerance
Information obtained by the probe:
• Probing depth (PD) / Bleeding on probing (BOP)
• Clinical Attachment level (CAL)
• Furcation involvement (using Naber’s probe)
• Root deposits
• Anatomy of the root
• Configuration of the pocket
• Bone sounding/configuration of the bony defects (under local anesthetics)
‣ From one visit to the next, it is difficult to duplicate precisely the
insertion force and to reproduce the angulation of the probe
‣ Because of technical problems, when consecutive readings of
insertion
PD are taken at a given site, it is generally expected that the
PD measurements may vary by up to 1 mm (reproducibility)
This is true of intra- and inter- examiner measurements
(Badersten, 84)
Clinical Significance of Probing Depth:
In untreated and treated patients when deep and shallow
periodontal pockets are compared, deep periodontal pockets are
associated:
‣ Increased BOP
‣ Higher levels of putative periodontal pathogens
‣ Reduced ability to remove subgingival deposits
‣ Decreased effectiveness of oral hygiene to alter subgingival microbiota
‣ More probing errors
‣ Greater amount of infiltrated connective tissue
▪ Therefore, recording PD measurements is an integral part of patient
evaluation and treatment planning.
Clinical Significance of Probing Depth:
• Persistent deep pockets (i.e., persisting after adequate and
appropriate treatment) are at greater risk for further attachment
loss (Badersten, 90; Claffey, 90). This was even more true of furcation sites
than interproximal sites (Claffey, 90)
• Recent Systematic review concluded that patients with deep
residual probing depts after therapy were more predisposed to
disease progression than patients with shallow sites (Renvert & person,
2002)
Clinical Attachment Level (CAL)
Clinical Attachment Level (CAL)
• The distance from CEJ to the tip of a periodontal probe during
usual periodontal diagnostic probing
• When CEJ is not detectable or missing, the CAL is measured
from a fixed reference point (margin of restoration or
incisal/occlusal edge of the tooth. This is called Relative
Attachment Level
Glossary of Periodontal Terms. 4th edition ; 2001. The American Academy of Periodontology
MEASURING CLINICAL ATTACHMENT LEVEL
• Measure the PD from gingival margin to tip of the probe.
• Then, measure the distance between the GM to CEJ:
o If GM coronal the CEJ record GM-CEJ as negative value (Example:
-3mm)
o If GM at the CEJ. record the GM-CEJ as 0mm
o If GM apical to CEJ (recession), record the GM-CEJ as positive
(example +3mm)
• Add PD to GM-CEJ measurement to calculate the CAL
• Note 7 mm probing depth at buccal of tooth # 37. As the location
of gingival margin is at CEJ, the CAL will be also 7 mm
fig.A: 8 mm probing depth at disto-lingual of tooth
#1.6. The gingival margin is about 1.0 mm coronal
CEJ. The CAL, then, will be 7 mm A
fig.B: 6 mm probing depth at disto-buccal aspect
of tooth # 2.6. Also, note location of gingival margin
relative to CEJ at the same site. There is 9 mm of clinical
attachment loss at the same site B
A
fig. A: the margin of gingiva at mesial of #1.4 is
located coronal to CEJ
fig. B: PD at mesial of #1.4 is 4 mm. since gingival B
margin is about 4 mm coronal to CEJ very minimal
attachment loss has occurred, if any. compare this
with fig. B in previous slide
C
fig. C: No radiographic evidence of bone loss at
mesial of #1.4
Clinical significance of CAL:
• Recording CAL is the most accurate way to monitor disease
progression because this measurement relates probing to fixed
reference point that will not be influenced by gingival margin
migrating apically or coronally
• Its’ use limited to clinical research and academic settings. Not used
in daily clinical practice. it is hard to locate CEJ and it requires more
time than PDs measurements
Points to ponder
• CAL = clinical attachment level
• CAL = clinical attachment loss
• Depending on context:
o When referring to periodontal disease process/progress, CAL refers to
clinical attachment loss (e.g. “Periodontitis: stage 1” is characterized
by 1-2 mm of clinical attachment loss (CAL)
o When referring to periodontal treatment outcome, CAL may refer to
Gain/Loss in clinical attachment as a treatment outcome. (e.g. non-
surgical periodontal treatment results in reduction in probing depth
and gain in clinical attachment level (CAL) in sites with initial probing
depth >5-6 mm)
Clinical Point # 1
• Would you diagnose tooth # 1.3 with periodontitis? Why?
• If you obtain a PA for tooth #1.3, would you expect a
radiographic evidence of bone loss? Explain!!
Clinical Point # 2
• Would diagnose tooth # 1.3 with periodontitis? Why?
• Would you take a PA for tooth #1.3? If you obtain a
PA for tooth #13, would you expect a radiographic
evidence of bone loss? Explain!!
End of Periodontal Examination Part-II
