Probing force and the relationship of the probe tip to the periodontal tissues

Abstract. Recently an increasing pocket depth was found to be related to an increasing probing force. The purpose of the present study was to investigate whether or not a plateau value in pocket depth measurements exists and to study, with different probing forces, the location of the tip of the probe in relation to the periodontal fibers and the alveolar bone. Two groups of patients were selected for this study; in one group a number of teeth had to be extracted for periodontal reasons (the extraction group) and in the other a single periodontal surgical procedure was required (the surgery group). All patients received preliminary treatment consisting of plaque control and removal of subgingival deposits. At the time of the investigation the gingival condition was assessed by means of a new index, the Periodontal Pocket Bleeding Index (P.P.B.I.) The criteria were: 0 - no bleeding of the pocket after probing with a force of 0.75N, and 1 - bleeding of the pocket within 30 sec after probing with a force of 0.75N. After local anesthesia in the extraction group, reference marks parallel to the long axis of the experimental teeth were cut with a cylindrical diamond burr. By means of the pressure probe, pocket depth measurements were performed with increasing forces of 0.50, 0.75, 1.00 and 1.25N. After extraction and staining of the remnants of the periodontal fibers, the distance from the most coronal intact connective tissue fibers to the most apical point of the reference marks was measured. In the surgery group using the same pressure probe, interproximal measurements with increasing forces of 0.50, 0.75, 1.00 and 1.25N were made from the apical border of the restorations to the bottom of the pocket. The same measurement, this time to the crest of the alveolar bone, was repeated after a flap had been raised. Results with the P.P.B.I. showed that oral hygiene procedures resulted in a mean index of 0.36 in the surgery group and 0.43 in the extraction group. The results of the present study indicated that 1) using a probe of 0.63 mm diameter, the optimal force level for clinical pocket depth measurements is 0.75N, 2) a force of 0.75N is clinically well tolerated and meets with few objections from patients, 3) when a probing force of 0.75N is used the tip of the probe in both shallow and deep periodontal pockets is located at the most coronal intact connective tissue fibers, 4) a plateau value in pocket depth measurements is found when a probing force of 1.25N is employed, and 5) the mean width of the connective tissue attachment is approximately 1.9 mm.     

Histologic probe position in treated and untreated human periodontal tissues

This study was designed to histologically determine the relationship of the periodontal probe tip to the periodontal tissues during probing of untreated periodontal pockets and periodontal pockets treated with oral hygiene and root planing. Human, condemned, single rooted teeth with buccal probing pocket depth at least 6 mm were used. Two groups of specimens were included: 12 untreated teeth from six patients and 15 treated teeth from 10 patients. In the treated group, the effects of therapy were monitored clinically every 2 weeks until maximum improvement had taken place. A periodontal probe tip was then inserted on the buccal aspect of the tooth using 0.50 N pressure, and block section biopsies were taken. The histologic examination of the untreated teeth showed that the probe tip penetrated beyond the apical termination of the junctional epithelium and into the subjacent connective tissue by a mean of 0.45 +/- 0.34 mm, whereas in the treated specimens the probe stopped coronally to this landmark by a mean of 0.73 +/- 0.80 mm. This study demonstrated that the probe tip most often does not reach the base of the junctional epithelium in pockets treated by plaque control and root planing, and that clinical measurements of attachment levels are not reliable in determining the true histologic level of connective tissue attachment.     

A new periodontal probe with automated cemento-enamel junction detection

A new automated periodontal probe has been developed which measures attachment level relative to the cemento-enamel junction in a single measurement. The probe tip automatically enters the periodontal pocket and retracts under controlled force. As the probe tip transverses the cemento-enamel junction, the electronics detect an alteration in the acceleration of the probe tip. Thus, the location of the cemento-enamel junction is determined automatically. The repeatability and accuracy of the probe was assessed in vitro. Measurements of attachment level were repeatable to 0.03 mm, and the probe had a net accuracy of 0.04 mm.     

Treatment of periodontal infections due to anaerobic bacteria with short-term treatment with metronidazole

Abstract In the present report, five selected periodontal patients were treated for 1 week with metronidazole. Two of the patients had their teeth scaled and root-planed the week they received metronidazole. Prior to treatment, B. asaccharolyticus accounted for 41 % of the cultivable isolates and the spirochetes averaged 29 % of the microscopic count in plaque removed from each of four pockets per patient. The presence of these elevated proportions of periodontopathic bacteria combined with the presence of periodontal pockets and attachment loss suggested that the patients were in a state of an active infectious process involving primarily anaerobic bacteria. If this be the case, then antimicrobial therapy directed against these anaerobes with metronidazole was indicated. The 1-week treatment with metronidazole significantly reduced the proportions of these organisms for up to 6 months after treatment. Coincident with these findings was an improvement in the clinical parameters, especially in those sites that initially had greater than 5 mm pocket or attachment loss. These sites showed a 2 mm or more reduction in pocket depth and an almost 2 mm gain in apparent attachment that was evident 6 months after treatment. The results obtained were in only five patients. However, the magnitude of improvement suggests that antimicrobial therapy directed against anaerobic organisms may be a valuable adjunct to periodontal therapy.     

Microbial succession in recolonizing deep periodontal pockets after a single course of supra- and subgingival debridement

In the present study, the effect of supra and subgingival plaque debridement on the dynamics of the subgingival microflora in deep pockets was investigated. 8 adult periodontitis patients participated in the study. In each patient, 4 clinically diseased sites were investigated microbiologically by phase contrast microscopy for the determination of both the %s as well as the total numbers of spirochetes and motile rods and by anaerobic cultivation for the determination of the different black-pigmented Bacteroides species. After base-line examination, patients were treated by mechanical removal of supra- and subgingival plaque deposits. 2 and 8 weeks after treatment, clinical and microbiological parameters were re-evaluated. During the experimental period, no oral hygiene procedures were performed in order to achieve fast recolonization of the pockets. Treatment resulted in a significant reduction in probing pocket depth and gain of probing attachment. 2 weeks after treatment, no further improvements could be observed. A positive correlation was found between the reduction in probing pocket depth and decrease in Bacteroides gingivalis (P less than 0.009) and between gain in probing attachment and reduction in the % of B. gingivalis (P less than 0.009). No correlation between these clinical parameters and B. intermedius, spirochetes or motile rods was apparent. An inverse relationship between B. gingivalis and B. intermedius was observed. We found that changes in %s of spirochetes and motile rods are not correlated with changes in total numbers of these bacterial groups. It was concluded that monitoring of %s of micro-organisms may not supply rational information on the microbiological conditions of the subgingival area.     

Subgingival microflora in bleeding and nonbleeding pockets

Abstract The subgingival flora of bleeding and nonbleeding 4–6 mm pockets was investigated using phase-contrast microscopy. Subgingival plaque was sampled from 11 patients with generalized moderate periodontitis. 4 subgingival samples were obtained from each patient, 2 from sites that bled upon standardized probing force and 2 from sites that did not. The amounts of gingival inflammation, supragingival plaque, attachment level and pocket depth were also assessed at each site. The %s of 4 bacterial morphotypes were assessed using phase-contrast microscopy. No significant differences were found in the %s of cocci, motile rods, or spirochetes between bleeding and nonbleeding sites. Significant correlations were found, however, between the % of spirochetes and probing depth, attachment level, and gingival inflammation. The observations indicate that the use of bleeding on probing may not be justified as an indicator of infection by those “periodontopathic” bacteria identifiable by phase-contrast microscopy. However, limitations in the microscopic method may have prevented us from observing differences between the 2 types of sites on a species level.     

Relationship between periodontal probing velocity and gingival inflammation in human subjects

Abstract Little is known about the biophysical characteristics of the dentogingival junction in response to the development or resolution of inflammation. The Toronto Automated Periodontal Probe (TAPP) provides an estimate of the integrity of the dentogingival junction by measuring intrapocket probing velocity. The aim of this study was to measure changes of probing velocity in inflamed human periodontium before and after subgingival debridement. 32 subjects exhibiting gingival inflammation were selected; 29 completed the study. Gingival index (GI), plaque index (PLI), bleeding index (BI) and the rate of gingival crevicular fluid flow (CFF) were measured as concomitant variables. The experimental group (N= 16) received scaling, root planing and oral hygiene instruction at baseline. The control group (N=13) received no treatment until after 28 days. Subjects were seen at baseline, day 14, 21 and 28 for measurement of probing velocity and concomitant variables on 6 index teeth. At day 28, the control group was treated and then reassessed 28 days later. The experimental group showed a reduction of 51.6% for mean crevicular fluid flow (p<0.0001), 79.7% for mean plaque index (p<0.0001), 58.0% for mean gingival index (p<0.0001), and 72.0% for mean bleeding index (p<0.002) at day 28, confirming that inflammation was reduced compared with baseline. No significant changes were observed in the control group until after treatment. The velocity of probing and the formation of a plateau in the velocity profile were recorded. The experimental group demonstrated a significant increase (p<0.002) in the frequency of plateau formation and a decrease in mean slope between baseline and day 28 (p<0.02). No significant change was observed in the control until day 56, 28 days after treatment. These data indicate a direct relationship between improved clinical health and increased resistance to probe penetration near the base of the pocket, as reflected by the increased frequency of plateau formation and decreased slope for the terminal segment of the velocity profile curve.     

Comparative analysis of the effect of 4MATRIX with and without PRF on regeneration of infrabony periodontal pockets

AimThe aim was to compare the effect in improvement of periodontal pocket depth (PPD) and clinical attachment level (CAL) between application of 4MATRIX and 4 MATRIX combined with PRF in advanced periodontal disease during follow-up of 6, 12 and 18 months.MethodsThirty patients of both genders aged 25–50 years were included. The patients were clinically and radiologically diagnosed with generalized advanced chronic periodontitis with the presence of periodontal pockets with a depth of ≥ 5 mm bilaterally in the upper jaw. Both sides were treated with a flap intervention in all patients. On one side a bone substitute 4MATRIX was applied, and the other side was treated with an application 4MATRIX and PRF. The clinical assessment and measurements were performed in four stages, immediately before the intervention, and then 6, 12 and 18 months after the intervention. PPD and CAL were determined in all four timepoints.ResultsPPD was the highest at zero time before the surgery for both groups and was 5.56 ± 0.28 mm. In the postoperative follow-up period, the PPD value decreased gradually with the lowest average value of 5.10 ± 0.18 mm after 18 months in Group I and 4.67 ± 0.13 mm in Group II (p < 0.001, respectively). Moreover, comparing the values of PPD at 6, 12 and 18 months after the surgery, a significant difference was found between the patients from the 4MATRIX vs 4MATRIX + PRF (p < 0.001 respectively). The postoperative follow-up period showed a decrease in CAL value with the lowest value after 18 months. A significant difference in CAL was found between the four measurement times (p < 0.001, respectively). The average level of CAL was the highest before surgical treatment in both groups. The intergroup analysis of CAL after 18 months in group I (4MATRIX) was 5.27 ± 0.17 mm and in group II 4.10 ± 0.14 mm (p < 0.001).ConclusionTreatment of adult patients with advanced chronic periodontitis with periodontal pockets of ≥ 5 mm bilaterally in the upper jaw using 4MATRIX and 4MATRIX + PRF showed improvement of PPD and lower CAL loss after 18 months of the treatment. In the group treated with 4MATRIX + PRF patients showed the highest improvement in PPD and CAL loss. The analysis of treatment with 4MATRIX and 4MATRIX + PRF showed the lowest values after 18 months of the treatment.     

Long-term effects of supportive therapy in periodontal patients treated with fibre retention osseous resective surgery. I: recurrence of pockets, bleeding on probing and tooth loss

BACKGROUND: Periodontal surgery is indicated in the treatment of persistent pockets following cause-related therapy. The aim of this study was to evaluate the long-term effect of supportive therapy in periodontal patients treated with fibre retention osseous resective surgery. METHODS: Three-hundred and four consecutive patients were identified and retrospectively examined while presenting for a supportive periodontal care (SPC) appointment (T2). All had received non-surgical periodontal treatment and osseous resective surgery as needed, to obtain no sites with probing depth (PD) >3 mm before being enrolled in the SPC programme. The mean SPC duration for the patients was 7.8+/-3.2 years while the mean interval of SPC was 3.4+/-0.8 months. RESULTS: During SPC, a total of 67 teeth had been removed (0.9%). At T2, mean full-mouth plaque scores (FMPS) was 13+/-11.3% and full-mouth bleeding scores (FMBS) was 2+/-3%. In 98.5% of the sites, PD was minimal (or=6 mm was 68 and limited to 41 patients (13.8% of sample). Initial periodontal diagnosis of severe periodontitis, smoking habits, FMBS, number of teeth at completion of active periodontal therapy (T1), number of surgically treated teeth, number of teeth with furcation involvement and number of multi-rooted teeth were associated with the number of pockets at T2. A total of 598 sites (2.1%) displayed bleeding on probing (BOP) at T2. The odds ratio of sites 4 mm or deeper to be BOP positive was 32.9 compared with sites of <3 mm depth. Gender, FMBS, FMPS, furcation involvements and overall number of pockets were associated with the number of bleeding pockets at T2. CONCLUSION: Shallow PDs achieved by treatment of the persistent pockets by fibre retention osseous resective surgery can be maintained over time. These patients displayed minimal gingival inflammation and tooth loss during SPC.     

Correlation between electronic and visual readings of pocket depths with a newly developed constant force probe

The purpose of this study was to compare probing measurements obtained using a newly developed constant force electronic probe, which eliminates errors of visual reading and variable force, to those obtained using a standard periodontal probe. The probe was connected to a digital readout through a linear variable differential transformer; the digital readout was connected to a printer and a foot switch. When the probe was in position and the foot switch depressed, the pocket depth was printed to the nearest 0.1 mm. 12 subjects with minimal to early periodontitis were selected for the study. The pocket depths of each patient were recorded electronically utilizing a constant force of 25 g, and conventionally using the same instrument in a "locked" position and visual reading. Probings were performed on each subject by 3 different examiners, on 3 separate occasions 2-3 days apart. The results showed a high correlation between manual and electronic probing. The average correlations for the 3 investigators between examinations were consistently higher for the electronic probings. In comparing the 3 examiners to each other, consistently higher correlations were found for the electronic pocket readings. Correlations for single-rooted teeth were lower for all 3 examiners. The pocket depth measurements recorded when using the manual probe with visual readings were consistently deeper than those obtained using the electronic probe with computer readings. It was concluded that the reproducibility of measurements obtained with the electronic probe was significantly superior to that obtained with a manual probe.     

Clinical changes in periodontium during pregnancy and post-partum

Background and Aim: Pregnancy has been presented to increase susceptibility to gingival inflammation. It is unclear whether pregnancy gingivitis exposes or proceeds to periodontitis. We examined longitudinally the severity of periodontal changes during pregnancy and post-partum, and compared the findings with an age-matched group of non-pregnant women.
Material and Methods: Thirty generally healthy, non-smoking women at an early phase of their pregnancy and 24 non-pregnant women as controls were recruited. The pregnant group was examined three times during pregnancy and twice during post-partum, and the non-pregnant group three times, once per subsequent month. At each visit, visible plaque index (VPI), bleeding on probing (BOP), probing pocket depth (PPD), and clinical attachment level (CAL) were measured from six sites per tooth.
Results: In the pregnant group, BOP and PPD increased simultaneously without relation to plaque between the first and second trimesters, and thereafter decreased during subsequent visits. No changes were detected in CAL during the study period. In the non-pregnant group, BOP stayed invariable during the follow-up and correlated with the amount of plaque. Neither periodontal pocket formation nor significant changes in attachment levels were observed.
Conclusion: Based on this study, changes in clinical parameters during pregnancy are reversible, indicating that pregnancy gingivitis does not predispose or proceed to periodontitis.     

Ultrastructural localization of glycosaminoglycans in human gingival connective tissue using Cupromeronic blue

Human gingiva was stained with cupromeronic blue according to Scott's critical electrolyte concentration technique in order to localize glycosaminoglycans (GAG) in the electron microscope. Identification was performed by digestion with chondroitinase AC, ABC and heparinase. The GAG were localized in three compartments of the connective tissue: the supra-alveolar fiber apparatus, the loose connective tissue and the basement membranes. In the supra-alveolar fiber apparatus, consisting mainly of densely packed parallel collagen fibrils, dermatan sulfate GAG are regularly attached to the d-band of the collagen fibrils. The precipitates (6–7 nm in diamter) aggregate to thicker precipitates (up to 16 nm), thus possibly providing stability to the fiber system. In the loose connective tissue with sparse collagen fibrils dermatan and chondroitin sulfate GAG form very large precipitates (up to 30 nm in diameter and 400 nm length) which interconnect the few collagen fibrils. The basement membranes of the epithelium and capillary endothelium contain heparan sulfate GAG as fine precipitates (4–6 nm in diameter) which form a meshwork. These findings are consistent with the Scott model (1) for the interactions among glycans and glycans and collagen fibrils in connective tissues.     

Histological evaluation of periodontal probe penetration in untreated facial molar furcations

Abstract The purpose of this investigation was to histologically determine the position of the periodontal probe tip when probing the deepest in terra dicular pocket depth in grade II and III facial molar furcation sites. Facial furcation pockets (5.8 mm+ 1.3) were probed with a pressure-sensitive probe set at 50 g pressure. The probe tip was attached to the tooth with an acid etched composite resin. Surgical block biopsies were removed, fixed, decalcified and processed for histological sectioning. Buccolingual serial sections (6 μ) were cut from 9 biopsies and apicocoronal serial sections were cut from 3 biopsies. The sections were histometrically analyzed. The probe tip penetrated the inflamed furcation connective tissue an average depth of 2.1 mm (±0.6), The probe tip was located 0.4 mm (± 1.4) apical to the crest of the interradicular bone. The % of inflammatory cell infiltrate in the connective tissue (ICT) around the probe tip was 56% (± 15%). There was no correlation between the % of ICT and the depth of probe penetration. This investigation demonstrated that probing of untreated facial molar furcation sites does not measure the attachment level of the interradicular root surfaces, but rather records the depth of probe penetration into the inflamed furcation connective tissue.     

Interest in periodontology and preferences for treatment of localized gingival recessions

OBJECTIVES: The purpose of this study was to evaluate the views, knowledge and preferences of a large sample of practising dentists in periodontics, focusing specifically on the treatment of gingival recessions, and to compare the findings with the current evidence available in the dental literature. METHODS: We conducted a cross-sectional postal survey of 3780 dentists, representing the majority of all dentists working in Switzerland. The questionnaire consisted of 17 questions, most of them giving the possibility of multiple choices of answers. The demographic profile, interests and satisfaction in periodontics were associated with the choice of treatment options offered for the management of six clinical situations. RESULTS: One thousand two hundred and one dentists sent back the questionnaire within three months and were thus included in the analysis. In general, the interest and the satisfaction in periodontics were moderate to high (6-7 on an analogue scale from 1 to 10). Specialists in periodontics indicated a significantly higher interest and satisfaction in periodontics than the general dentists (p<0.001), and practitioners working in urban areas indicated a slightly higher interest (p=0.027) and satisfaction (0.047) than their colleagues established in a rural setting. The predominant indication of root coverage procedures was aesthetics (90.7%). The region in which dentists worked was the only significant predictor for choosing "no treatment" of buccal recessions: dentists from the German-speaking part were significantly less inclined to surgically treat gingival recessions than their colleagues from the French or Italian part. For those who opted for therapy, a free tissue graft was generally the favourite option, followed by a connective tissue graft and a coronally advanced flap. Throughout, only a small fraction of the dentists considered using a guided tissue regeneration procedure. The relative odds for not extracting teeth with severe periodontal disease were higher if the dentist was a specialist than a generalist. Satisfaction in practicing periodontics also positively strengthened the inclination towards keeping severely compromised teeth. CONCLUSIONS: Aesthetic concerns were the predominant indication for root coverage procedures. Further research should therefore include aesthetic aspects as primary clinical outcome variables. Specific training of dentists and their satisfaction in periodontics influenced treatment decisions. Specialists involved in continuing education should inform practicing dentists more efficiently on the potential and usefulness of periodontal therapy for saving and maintaining periodontally compromised teeth.     

The use of a triclosan/copolymer dentifrice may retard the progression of periodontitis

Abstract The present investigation was performed to examine if triclosan and a copolymer, incorporated in a dentifrice and used by periodontitis-susceptible subjects could influence clinical symptoms characteristic of recurrent periodontitis. 60 subjects, 34 to 67 years of age, were recruited for the study. They were randomly selected from a group of patients previously treated for advanced periodontal disease. This treatment had included oral hygiene instruction, subgingival debridement, but no surgical therapy. The patients had, during a 3-5 year period following active therapy, been enrolled in a maintenance care program but had, at various intervals, exhibited signs of recurrent periodontitis. The patients were stratified into 2 balanced groups with respect to mean probing pocket depth. The test group, included 30 individuals who used a dentifrice containing triclosan/copolymer/fluoride, i.e. 0.3% triclosan, 2% copolymer and 1100 ppm F from 0.243% sodium fluoride (Colgate Total®). The control group also included 30 subjects who used a dentifrice identical to the one used in the test group but without the triclosan/copolymer content. Following the baseline examination, including clinical and radiographical assessments, all volunteers received detailed information on how to brush their teeth in a proper way. This information was repeated on an individual need basis during the course of the subsequent 36 months. No professional subgingival therapy was delivered between the baseline and the 36-month examinations, but the subjects were recalled every 3 months. Re-examinations were performed after 6, 12, 24, and 36 months of the trial. A 2nd set of radiographs was obtained at the final examination, i.e., at 36 months. The restilts demonstrated that in subjects susceptible to periodontal disease, meticulous, self-performed, supragingival plaque control maintained over a 3-year period failed to prevent recurrent periodontitis. In a similar group of subjects and plaque control program, however, the daily use of a triclos-an-containing dentifrice reduced (i) the frequency of deep periodontal pockets, and (ii) the number of sites that exhibited additional probing attachment and bone loss.     

Evaluation of 2 methods to assess gingival bleeding in smokers and non-smokers in natural and experimental gingivitis

Abstract. The purpose of the present study was to compare the bleeding tendency as elicited by probing the marginal gingiva (BOMP) and probing to the bottom of the pocket (BOPP) in smokers and non-smokers in natural gingivitis and during experimental gingivitis, 11 smokers (sm) and 14 non-smokers (nsm) were recruited. When they had less than 20% approximal bleeding sites, they entered a 14-day trial period of experimental gingivitis'. Subjects returned 30 days later, after resuming normal oral hygiene procedures, for a final gingival assessment. A split-mouth design was chosen using 2 contra-lateral quadrants for each index (being either BOMP or BOPP). A consistently higher bleeding score of approximately 10% was observed by probing to the bottom of the pocket. At day 14 with both indices, a significant difference between smokers and non-smokers was detected (BOMP: sm=15%, nsm = 30%; BOPP: sm = 27%, nsm=44%). The increment between gingival health and experimental gingivitis was significantly higher in non-smokers than in smokers but comparable for both indices (BOMP: sm=8%, nsm = 23%; BOPP: sm=9%, nsm=26%). Probing to the bottom of the pocket results in significantly more bleeding in gingival health and gingivitis as compared to probing of the marginal gingiva. This shows that evaluation of the gingival condition with BOMP, the method of choice with respect to gingivitis, can be used as a parameter for inflammation when comparing smokers and nonsmokers. The suppressed inflammatory response to plaque accumulation, as observed in smokers, indicates that they should be identified as a separate group when they participate as panellists in (experimentally induced) gingivitis