Periodontal Probing Versus Radiographs for the Diagnosis of Furcation Involvement.

Christian Graetz , Anna Plaumann , Jan-Fredrik Wiebe , Claudia Springer ,Sonja Salzer and Christof E.Dorfer.

J Periodontol 2014;85:1371-1379

Dr Shivani Iyer PG 1st Year

Army College Of Dental Sciences

CONTENTS

1. Introduction2. Materials and Methods 3. Results 4. Discussion5. Related Studies6. Conclusion 7. References

INTRODUCTION

The progress of inflammatory periodontal disease , if unabated , ultimately results in attachment loss sufficient enough to affect the bifurcation or trifurcation of multirooted teeth.

The furcation is an area of complex anatomic morphology, that may be difficult or impossible to debride by routine periodontal instrumentation.

What is FURCATION ?

TERMINOLOGY

Root complex is the portion of a tooth that is located apical of the cemento-enamel junction (CEJ).

The root complex may be divided into two parts:

a. The root trunk : represents the undivided region of the root

b. The root cone : is the divided region of the root complex.

The furcation is the area located between individual root cones.

Furcation entrance :the transitional area between the undivided and the divided part of the root

Furcation fornix :the roof of the furcation

Degree of separation :the angle of separation between two roots cones.

Divergence :distance between two roots.

Divergence and degree of separation between palatal and mesial roots.

ANATOMY OF MAXILLARY MOLARS

Mesial view of maxillary 1st molar

Mesial furcations located 2/3rd towards palate. Furcation probed from palatal side.

Distal view of maxillary 1st molar

Located mid-way buccolingually.Probing from both the sides.

A. B.

DIAGNOSIS

1. Clinical Examination2. Careful Probing 3. Radiographic View 4.Transgingival sounding.

NABERS PROBE

Furcation areas can be best evaluated with the curved , blunt Nabers Probe. These are of two types :-

1. Nabers 1N Probe : specifically designed for mesial & distal furcations on maxillary molar.

2. Nabers 2N Probe : accesses all buccal and lingual furcations and mesial and distal furcations. It also facilitates access to any furcation with a long root trunk and/or deep pocket.

ETIOLOGY

Prolonged presence of microbial dental plaque.

Extent of attachment loss on furcation depends on the presence of these factors :

Root trunk length Root length Root formInterradicular dimension.Anatomy of Furcation.Cervical enamel projections.

Classification of Furcation Involvement

Glickman’s Classification ( 1953 )

1. GRADE I

This is an early or incipient stage of furcation involvement.

The pocket is suprabony and primarily affects the soft tissues.

Early bone loss may have occurred with an increase in probing depth.

Radiographic changes not found.

2. GRADE II

Furcation lesion is essentially cul-de-sac, with a definitive horizontal component.

Vertical bone loss may be present.

Radiographs may or may not depict the furcation involvement particularly in maxillary molars because of the radiographic overlap of the roots

3. GRADE III.

In grade III furcation , the bone is not attached to the dome of the furcation.

In early Grade III involvement , the opening may be filled with soft tissue & may not be visible.

The clinician may not be able to pass the periodontal probe through the furcation because of the interference with the bifurcational ridges or facial/lingual bony plate margins.

Properly exposed and angled radiographs of early class III furcation display the defect as a radiolucent area in the crotch of the tooth.

4. GRADE IV

The interdental bone is destroyed.

Soft tissues have receded apically so that the furcation opening is clinically visible.

A tunnel therefore exists between the roots of such an affected tooth.

Hamp, Lyman & Lindhe (1975 )

This classification is based on the amount of periodontal tissue destruction that has occurred in the inter – radicular area , i.e degree of horizontal root exposure or attachment loss that exists within the root complex.

Degree I : horizontal loss of periodontal support not exceeding one third of the width of the tooth.Degree II : horizontal loss exceeding 1/3rd of the width of the tooth. not encompassing the total width of the furcation area.Degree III : horizontal “through and through” destruction of the periodontal tissues in the furcation area.

TARNOW/ FLETCHER ( 1984)

A- Vertical destruction of bone upto 1/3rd of the inter-radicular height (0-3mm)

B-Vertical destruction of bone upto 2/3rd of inter-radicular height (4-7mm)

C- Vertical destruction beyond the apical third (>7mm)

Takes into account vertical bone loss from roof of furcation apically

To evaluate the validity of FURCATION PROBING ( FP ) and

RADIOGRAPHIC ASSESSMENT of FURCATION INVOLVEMENT

(FI) compared with visual assessment during OPEN FLAP SURGERY (

OFS )

AIM OF THE STUDY

MATERIALS AND METHODS

STUDY DESIGN

1. A total of 834 molars were assigned for FI by FP and in radiographs analyzed by an experienced (EE) and less experienced examiner (LE).

2. For the investigation, 143 panoramic radiographs (OPG) and 77 intra-oral radiographs (I-O) were evaluated.

RESULTS

Kappa k

Kappa co-effiecient is intended to give the reader a quantitative measure of the magnitude of agreement between observers.

Kappa Agreement< 0 Less than chance agreement0.01–0.20 Slight agreement0.21– 0.40 Fair agreement0.41–0.60 Moderate agreement0.61–0.80 Substantial agreement0.81–0.99 Almost perfect agreement

FP Region Confirmed by OFS ( % )

Overestimated compared with OFS ( % )

Underestimated Compared with OFS ( %)

TOTAL 56.2 14.8 29.0Maxilla 53.8 16.3 29.9

Mandible 59.3 12.9 27.9

Agreement of FI Diagnosed by Clinical Probing With a Nabers Probe (FP) Compared with the Situation Observed During OFS

The degree of agreement between FP & OFS was slightly better for Mandible ( 59.3 % , k = 0.629 ) compared with the maxilla ( 53.8 % , k = 0.550)

The class of FI by FP was confirmed in 56 % , whereas 15 % were overestimated & 29 % underestimated.

The best correlation of FP and OFS was found in the mandible for the first left molar (kw = 0.690) and in the maxilla for the second right molar (kw = 0.637 )

Of all furcations diagnosed as Class III during OFS, 68.1% were not detected correctly by FP (maxilla 66.2% and mandible 71.4%).

The mean agreement between FP and OFS for all investigators was kw = 0.588

Radiographic Diagnosis Versus Assessment During OFS

Overall, 524 furcations were analyzed by OPG & 310 by I-O.

The LE was not able to evaluate the FI in 30 cases (3.6% of 834 molars) and set these as FI Class ‘‘f’’ (EE: no cases).

Furthermore, LE did not find any FI Class II by OPG or I-O.

Missing an FI Class III by radiographs was more likely in the maxilla compared with the mandible.

The agreement of OFS and radiographs was kw = 0.542 (OPG kw = 0.555 and I-O kw =0.521) for both examiners.

A slightly better agreement was found for the mandible, with 52.3% (kw = 0.619) versus 44.5% (kw = 0.477) in the maxilla.

The best correlation of OPG and OFS was found at the first left molar in the mandible (EE kw = 0.876; LE kw = 0.629).

Influence of Examiner Experience and Tooth Anatomy

Overall the accuracy of the FI assessment by radiography seemed to depend on the examiner’s experience :

EE kw = 0.618 LE kw = 0.426

DISCUSSION

This retrospective study evaluates whether clinical, radiographic, or a combined assessment of FI is most reliable to assess the degree of FI.

The advantage of this study design, aside from the large number of participants, is that the examinations were performed under the conditions of daily clinical practice by periodontists unaware of their participation in a study.

Study-related effects, such as a bias of the examiners, e.g., during clinical probing, could therefore be excluded.

ACQUISITION OF IMAGES

CONVENTIONAL VS. DIGITAL IMAGING METHODS

According to the study design of the current investigation, the authors used only conventional radiographs under the conditions of daily practice without any standardization devices.

Despite the extensive innovations in imaging methods in recent years, the traditional method of obtaining an image has basically remained the same.

Current imaging methods in periodontology have been thoroughly reviewed by Mol *.

The study concluded that digital imaging per se is not superior to film based radiographs in its ability to detect detailed periodontal structures.

*Mol A. Imaging methods in periodontology. Periodontol 2000 2004: 34: 34–48.

It seems indisputable that the force during clinical probing of the furcation the size and design of the probe and the experience and the training of the examiner influence the clinical assessment of the FI.

Kims TS et al ( 1982 )* studied the reproducibility & validity of furcation measurements using the pressure - calibrated probe.( 0.25 N ) which is a flexible plastic universal version of the TPS ( True Pressure Sensitive ) probe.

The horizontal probing attachment level (PAL-H) of 100 furcation involved molars on 25 patients was investigated

The measurements were repeated using a colour-coded Nabers probe and compared to the TPS assessments.

The study concluded TPS probe unsuitable for proper assessment of the degree of furcation involvement.

* Kim TS, Knittel M, Staehle HJ, Eickholz P. The reproducibility and validity of furcation measurementsusing a pressure-calibrated probe. J Clin Periodontol 1996;23:826-831.

1. Ross IF, Thompson RH Jr et al

Study found a more reliable assessment of FI in maxillary molars by radiography than by clinical examination, which was opposite for the mandible. The findings for the maxilla corresponded to the present results.

2. Gurgan et al evaluated radiographic assessment of artificial bony defects with the corresponding buccal FI Class I and II in the mandible with a high correlation within the 12 observers (68% and 86%) and without significant difference between mandibular first and second molars, similar to the present investigations

RELATED STUDIES

3. Eickholz and Kim showed that straight probes may increase the underestimation of diagnosis and, therefore, recommended curved probes as used in this study.

4. Zappa et al. in a similar investigation with six involved dentists after diagnosis of 1,180 clinical furcations found a higher degree of agreement of clinical probing to OFS for mandibular molars. ( k = 0.629 )

CONCLUSION

For experienced operators , the combination of radiographic imaging of furcations and clinical probing is most reliable.

It cannot be concluded by the data of this study which degree of clinically examined FI necessitates further radiographic diagnostic techniques such as I-O or OPG.

Therefore , the gold standard remains visual control during OFS.

REFERENCES

1. Carranza’s Clinical Periodontology, 10th edition.

2. Clinical Periodontology & Implant Dentistry , 5th edition Volume 2 – Jan Lindhe

3. Fleiss JL, Cohen J, Everitt BS. Large sample standard errors of kappa and weighted kappa. Psychol Bull1969;72:323-327.

4. Bragger U. Radiographic parameters: Biological significanceand clinical use. Periodontol 2000 2005;39:73-90.

5. Mol A. Imaging methods in periodontology. Periodontol2000 2004: 34: 34–48.

6. Kim TS, Knittel M, Staehle HJ, Eickholz P. The reproducibility and validity of furcation measurements using a pressure-calibrated probe. J Clin Periodontol1996;23:826-831.

Thank you