PERIODONTAL PROBING AND TECHNIQUES

By Dr Johnn Kazimm

DEPARTMENT OF PERIODONTICSAT

I.T.S DENTAL COLLEGE, HOSPITAL & RESEARCHCENTRE, GREATER NOIDA

INDEX• Introduction• History• Standard Periodontal Probe• Classification• Types of Periodontal Probe• Probing technique• Pressure Sensitive Probe• Principles• NIDCR Criteria• Florida Probing System• Per implant Probing• Conclusion• References

DEFINITION

• PERIODONTAL PROBE

• A calibrated probe used to measure the depth and determine the configuration of a periodontal

pocket.(1)

• The Latin word probo means “to test.”

• 1882 – John W Riggs – described probe.

• Between 1915 and 1958, several studies supported use of the periodontal probe to determine the disease status of gingival tissues.(2)

• Periodontal probe and its use was first described by F.V. Simoton of the University Of California, San Francisco in 1925. (3)

• Miller suggested probing of all pockets and recording their depth and putting this information on diagnostic chart.(4)

• Simonton proposed flat probes 1 mm wide, 10 mm long, and notched every 2 mm. Box used special gold or silver

probes that had different angulations.

• Orban (1958) described the periodontal probe as “the eye of the operator beneath the gingival margin.(5)

Goldman & Glickman

• Goldman et al . stated that "Clinical probing with suitable periodontal instruments such as the Williams calibrated probe is a prime necessity in delineating the depth, topography and character of the periodontal Pocket “ .(6)

• Glickman I stated that "The probe is an instrument with a tapered rod-like blade which has a blunt and rounded

tip.“(7)

• The probes most commonly used today were developed by Ramfjord in 1959.

“ the probes in use at that time were too thick to probe narrow clinical pockets and designed a round probe with a tip diameter of 0.4 mm

“(8)

• In 1967, Clavind and Loe reported the results of a research protocol in which they used a periodontal probe tip that was 0.8 mm in diameter with a 10 gram force.(9)

• In 1992, B. L. Pihlstrom created a classification of periodontal probes. (10)

• The classification system included three generations of probes: first, second and third generations.

• In 2000, Watts extended the classification system to include a fourth and fifth generation of probes.(11)

FIRST GENERATION

• First-generation probes -> manual, handheld instruments, also called conventional probes.

• In 1936, Charles H. M. Williams -> The Williams’ probe,13 millimeters in length and one millimeter in diameter, with demarcation lines at 1, 2, 3, 5, 7, 8, 9 and 10 millimeters.(12)

University Of North Carolina-15

• UNC-15 :

• 15-mm-long probe with markings at each millimeter

• Colour Coding at the 5th,10th and 15thmm.

Carranza's Clinical Periodontology e-dition, 10th EditionBy Michael G. Newman, DDS, Henry Takei, DDS, Perry R. Klokkevold, DDS, MS and Fermin A. Carranza, Dr. Odont

MICHIGAN “O” PROBE

.

Carranza's Clinical Periodontology e-dition, 10th EditionBy Michael G. Newman, DDS, Henry Takei, DDS, Perry R. Klokkevold, DDS, MS and Fermin A. Carranza, Dr. Odont

Markings are at 3, 6, and 8mm

NABER’S PROBE

• Determine the extent of furcation involvement on a multi rooted teeth.

• Curved working end for accessing the furcation area.

• The depth of insertion of the probe into the furcation area determines the degree of furcation involvement.Carranza's Clinical

Periodontology e-dition, 10th EditionBy Michael G. Newman, DDS, Henry Takei, DDS, Perry R. Klokkevold, DDS, MS and Fermin A. Carranza, Dr. Odont

GOLDMAN-FOX PROBE

Rectangular in cross section and has

millimeter markings(mm)

markings at 1-2-3-5-7-8-9-

10.Fundamentals of

Periodontal Instrumentation &

Advanced Root Instrumentation

By Jill S. Nield-Gehrig

WHO PROBE

• In 1978.• The probe was designed for two purposes:

-Measurement of pocket depth.-Detection of sub gingival calculus.

• Used in the assessment of CPITN (Community Periodontal Index for Treatment Needs)

• Weight = 5 gm

CPITN-E Probe (Epidemological Probe) Markings at 3.5 and 5.5mm.

CPITN-C Probe(Clinical Probe) Markings at 3.5, 5.5, 8.5 and 11.5mm.Ball Tip -> 0.5 mm

SECOND GENERATION PROBES

• Constant Pressure probes designed to provide for standardization of controlled probing pressure.

• Frank Hunter in 1994

• The TPS (True Pressure Sensitive) probe

• 20 grams of force

• Resistance and the indicator lines coincide, a constant pressure of

20 grams has been reached, and the reading is then taken. (13)

TRUE PRESSURE SENSITIVE PROBE

Periodontal ProSrinivas Sulugodu Ramachandra,

Periodontal Probing Systems: A Review of Available

Equipment.Dental ageisMarch 2011;32,(2) I

THIRD GENERATION PROBE

• Third-generation probes refer to automated probing systems.• Software integrates with existing computer systems to provide

computerized periodontal charting.

• The Florida Probe, first available in 1987, devised by Gibbs..is one such automated probing system that efficiently allows for hands free charting and generates a detailed, computerized periodontal chart.

• The Florida Probe has a constant pressure of 15 grams and a precision of

0.2 millimeters

• Toronto Automated Probes

THE FLORIDA PROBE

• Gibbs 1988• Probe hand piece and sleeve;• Displacement transducer

• Foot switch• Computer interface/personal computer. Probe tip has a

diameter of 0.45 mm, • Sleeve has a diameter of 0.97 mm . Constant probing

pressure of 15 gm is provided by coil springs inside the handpiece.(14) Periodontal ProSrinivas Sulugodu

Ramachandra, Periodontal Probing Systems: A Review of Available Equipment.Dental ageisMarch 2011;32,(2) I

INTER PROBE

.

Available At Interprobe.com

A flexible probe tip, which curves with the tooth as the probes

enter the pocket area.

Stainless steel probes push the gingiva away from the tooth, causing

pain, whereas the InterProbe gently

slides

FOURTH GENERATION PROBES

• Refer specifically to 3D technology,

• With the goal of obtaining a precise and continuous reading of the base of the sulcus or pocket.

FIFTH-GENERATION PROBES

• Designed to utilize ultrasound, in addition to 3D.

• Aim to accurately measure attachment levels without penetrating the Junctional epithelium

• For a more comfortable examination and a precise mapping

The US probe

• Was devised by Hinders and companion at the NASA Langley Research Center.• Small intraoral ultrasound beam projection area gives the Image of the periodontal

ligament space.

• To probe these structures ultrasonically, a narrow beam of ultrasonic energy is projected

Avaliable At www.USPROBE.COM

The Diamond Probe

• Detects periodontal disease during routine dental examinations by measuring relative sulfide

concentrations as an indicator of gram-negative bacterial activity.

Single-use disposable probe tip with microsensors connected to a main control unit.(15)

• The probe might detect periodontal disease at an early stage and might find an active site that

requires treatment. However, the probing

pressure is not controlled.

DIAMOND PROBE

Avaliable At www.devicelink.com/expo/old_awards/dntlnstrmnts

eq.html

PERIO – TEMP PROBE

• The Periotemp® Probe (Abiodent Inc, Danvers, MA) temperature-sensitive probe,

• detects early inflammatory changes in the gingival tissues by measuring temperature variations in these tissues.(16)

• Detects pocket temperature differences of 0.1oC from a referenced subgingival temperature.

• This probe has two light indicating diodes: red-emitting diode, which indicates higher temperature, denoting risk is twice as likely for future

attachment loss; and green-emitting diode, which indicates a lower temperature, indicating lower risk.

• This probe can detect initial inflammatory changes; therefore, treatment can be initiated at an early stage

Detec TAR• DetecTar’s fiber-optic probe reads light reflected off tooth structure

and transmits it to an internal computer for analysis. • DetecTar sounds a tone when it detects the unique spectral

signature of subgingival calculus

The probe tip emits light from a light-emitting-diode (LED). Reflected light -> analyzed by a microprocessor-supported-algorithm to determine the presence of calculus. When calculus is detected the system lights up and an audible “beep” occurs

Avaliable at www.dentistryindia.net/content/DI/img/20

09/05(17)

RELATED STUDIES

• Rams TE , Slots J (1993) (18)

• Three periodontal probes--a manual probe and two computerized, pressure-sensitive probes--were studied to determine their relative recording accuracy. Probing measurements were taken with the three probes at shallow (less than 5 mm) and deeper (greater than or equal to 5 mm) periodontal sites.

• Probing depths were determined on all teeth except third molars by the three probing techniques at a single appointment. All three probes demonstrated higher standard deviations with increasing depth, which indicates decreased reproducibility of probing depth measurements.

• Results ->• an electronic, pressure-sensitive probe yields more reproducible

probing depth measurements than a conventional manual periodontal probe

RELATED STUDIES

• L. Mayfield*,  G. Bratthall,  R. AttStröm(2005)(19)

• The aim of this study was to compare the relative intra- and inter-examiner reproducibility of 4 different periodontal probes. :

• 1.The Hu-Friedy LL 20 Probe, a manual probe. • 2.The Vivacare TPS Probe, a plastic manual probe with a standardised pressure of

0.20 3.The Vine Valley Probe, an electronic probe using a standardised pressure of 0.25

N• 4.The Peri Probe Comp, a computerised electronic probe with a controlled pressure

of 0.45 N

• Duplicate probing measurements were taken by 2 examiners in 10 patients on 3 Teeth ,were selected to incorporate both (<5 mm) (>5 mm) periodontal sites. The order of probes and examiners were changed in a systematic manner and measurements were repeated 1 week later to avoid bias due to examiner memory.

• Results show that the manual probe had the lowest degree of variation, with a correlation coefficient of 0.83.

• The manual and Peri Probe Comp frequently recorded deeper probing pocket depths compared to the TPS and Vine Valley probes.

RELATED STUDIES

• Garnick JJ ,Silverstein L(20) J Periodontol.2000

• The purpose of this study was to determine the importance of the diameter of periodontal probing tips in diagnosing and evaluating periodontal disease.

• Probe advancement between the gingiva and the tooth is determined by the pressure exerted on the gingival tissues and resistance from the healthy or inflamed tissue. The pressure is directly proportionate to the force on the probe and inversely proportionate to the probe tip diameter

• RESULTS:

• In the studies reviewed, the pressure used to place the probe tip at the base of the periodontal sulcus/pocket was approximately 50 N/cm2 and at the base of the junctional epithelium, 200 N/cm2. A tip diameter of 0.6 mm was needed to reach the base of the pocket. Clinical inflammation did not necessarily reflect the severity of histological inflammation.

• Probe tips need to have a diameter of 0.6 mm and a 0.20 gram force (50 N/cm2) to obtain a pressure which demonstrates approximate probing depth. This pressure was

needed to measure the reduction of clinical probing depth, which included formation of a long junctional epithelium as a result of therapy.

Factors Affecting Probing

• Design of the probe,• Probing force, • Probe position,• Probing direction• Pocket depth,

• Tissue inflammation.(21)

Design

• MILLIMETER MARKINGS ->

• 1. Millimeter Markings a. The working-end of the probe is marked at millimeter

intervals. • grooves, colored indentations, or colored bands may be used to

indicate the millimeter markings on the working-end.

• b. Each millimeter may be indicated on the probe or only certain millimeter increments may be marked

• 2. Color Coding. Color-coded probes are marked in bands (often black in color)

FUNCTION

.• Function ->

Determine the health of the periodontal tissues To measure pocket depths,

To measure clinical attachment levels, To determine the width of attached gingiva, to assess for the

presence of bleeding and/or purulent exudate (pus),and to measure the size of oral lesions.

Working End

Working‐End• Blunt• Rod‐shaped

Cross‐section• Round• Rectangular

Types• Calibrated• Non Calibrated Avaliable At

Wikipedia.org/periodotal probe.

PRINCIPLES

• ADAPTATION

• The side of the probe tip should be kept in contact with the tooth surface. The probe tip is defined

• as 1 to 2 mm of the side of the probe.

Correct In correct

PARALLELISMThe probe is positioned as parallel as possible to the tooth

surface.

• The probe must be parallel in the mesiodistal dimension

and faciolingual dimension.

Probe Parallel to Long Axis.Probe is correctly positioned parallel to the

long axis of the tooth.

Probe Not Parallel to LongAxis.

Probe is incorrectlypositioned in relation to the

long axis of the tooth.

TECHNIQUE

• Probing is the act of walking the tip of a probe along the junctional epithelium within the sulcus .

• THE WALKING STROKE

• The walking stroke is the movement of a calibrated probe around the perimeter of the base of a sulcus or pocket.( 22)

• Walking strokes are used to cover the entire circumference of the sulcus or pocket base.

• It is essential to evaluate the entire “length” of the pocket base because the junctional epithelium is not necessarily at a uniform level around the tooth.

PRODUCTION OF THE WALKING STROKE

1. Walking strokes are a series of bobbing strokes that are made within the sulcus or pocket. The stroke begins when the

probe is inserted into the sulcus while keeping the probe tip against the tooth surface.

2. The probe is inserted until the tip encounters the resistance of the junctional epithelium that forms the base of

the sulcus.3. Create the walking stroke by moving the probe up and

down in short bobbing strokes and forward in 1-mm increments .With each down stroke, the probe returns to touch the

junctional epithelium.4. The probe is not removed from the sulcus with each upward

stroke. 5. The pressure exerted with the probe tip against the junctional epithelium should be between 10 and 20 grams.

WALKING THE PROBE

Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation By Jill S. Nield-Gehrig

Gingival marginProbing depth

PROBING (ANTERIOR TOOTH)

• 1.Begin on the distofacial or

distolingual line• 2.Begin by inserting the probe at the

distofacial line angle • 3. Walk toward the distal surface.• 4. Assess beneath the contact area. Tilt the probe and extend the

tip beneath the contact area. • Press down gently to touch the

junctional epithelium• 5. Assess the facial surface. Make

a series of walking strokes across the facial surface.

• 6. Walk toward the mesial surface. Walk across the mesial surface until the probe touches the

contact area.• 7. Assess beneath the contact

area. On adjacent anterior teeth, only a slight tilt is needed to probe

the col area. • Gently probe the col area..

Probing(Posterior Tooth)

• 1. Assess beneath the contact area. Tilt the probe so that the tip reaches beneath the contact area (the upper portion of the probe touches the contact area).• Gently press downward to touch the junctional

epithelium.• 2. Reinsert at the distofacial line angle.

Remove the probe from the sulcus and reinsert it at the distofacial line angle.

• 3. Probe Site Make a series of tiny walking strokes across in a forward direction toward the mesial surface.

• 4. Walk the probe across the mesial surface until it touches the contact area.

• 5. Assess beneath the contact area. Tilt the probe and extend the tip beneath the contact area.

• 6. Press down gently to touch the junctional epithelium.

Jerry J. Garnick and Lee Silverstein.Periodontal

Probing.J Periodontal ;7(1) 2000

96-103

Measurement Of CAL,RAL

TRANSGINGIVAL PROBING1.Gingival Recession

2.Histological Probing

3.Clinical Probing4.Bone

sounding

PROBING HEALTHY VERSUS DISEASED TISSUE

• 1. Clinically Normal Sulcus• a. In health, the tooth is surrounded by a sulcus. The junctional epithelium

(JE) forms the base of the sulcus by attaching to the enamel of the crown near the cemento-enamel junction (CEJ).

• b. The depth of a clinically normal gingival sulcus is from 1 to 3 mm, as measured by a periodontal probe.

• 2. Periodontal Pocket

• a. A periodontal pocket is a gingival sulcus that has been deepened by disease.

• In a periodontal pocket, the JE forms the base of the pocket by attaching to the root surface somewhere apical to the CEJ.

• A periodontal pocket results from destruction of alveolar bone and the periodontal ligament fibers that surround the tooth.(22)

PROBING

.

Position of Probe in a Healthy Sulcus. In

health,the probe tip touches

the junctional epithelium

located above the cemento-enamel

junction.

Position of Probe in a PeriodontalPocket. In

aperiodontal pocket, the

probe tip touches the(JE) located on the

rootbelow the cemento-

enamel junction..

NATIONAL INSTITUTE OF DENTAL AND CRANIOFACIAL RESEARCH (NIDCR) CRITERIA FOR

OVERCOMING CONVENTIONAL PROBING(23)

PERI IMPLANT PROBING

• The results obtained with peri implant probing cannot be interpreted same as the natural teeth because:

- Differences in the surrounding tissues that support implanted teeth.- Probe inserts and penetrates differently.

- Around natural teeth, the periodontal probe is resisted by the insertion of supra-crestal connective tissue fibers into the cementum

of root surface. There is no equivalent fiber attachment around implants.(24)

PERI IMPLANT PROBING

Advantages:

- Can measure the level of mucosal margin relative to a fixed position on the implant.

- Measure the depth of tissue around the implant.-Periimplant probing depth is often a measure of the thickness of surrounding connective tissue and correlates most consistently

with the with the level of surrounding bone.

• The probing depth around implants presumed to be “healthy” has been about 3mm around all surfaces.

CONCLUSION

• Newer developments in the field of periodontal probes provide the potential for error-free determination of pocket depth.

• With more research and innovation, the advent of newer error-free probes may resolve the remaining problems and those yet

to be realized.

Thank you

REFERENCE

• 1.Glossary Of Periodontal Terms. 2001 4 th Edition

• 2. Box HK. Treatment of the Periodontal Pocket. Toronto: The University of Toronto Press; 1928:83

• 3. Simonton FV. Examination of the mouth-with special reference to pyorrhea. J Am Dent Assoc 1925;72:287 -295.

• 4. Miller SC. Oral Diagnosis and Treatment Planning. PhiladelphiaP: . Blakiston'sS on t' Co.; 1936:239.

• 5. Orban B, Wentz FM, Everett FG, Crant DA. Periodontics, A Concept-Theorg and Practice. St. Louis: C.V. Mosby Co.; 1958:103.

REFERENCE

• 6. Goldman HM, Schluger S, Fox L. PeriodontalTherapg. St. Louis: C.V. Mosby Co.; 1956:27.

• 7. Glickman l. Clinical PeriodontologgP. hiladelphia:W B. Saunders Co.; 1958:548.

• 8. Ramfjord SP. Indices for prevalence and incidence of periodontal disease. J Periodontol 1 959;30:5 1 -59.

• 9. Glavind L, Loe H. Errors in the clinical assessment of

periodontald estruction.J PeriodontR es'1967; 2:780-784.

REFERENCE

• 10. Pihlstrom BL. Measurement of attachment level in clinical trials: Probing methods. J Periodontol. 1992;63(12 Suppl):1072-1077

• 11. Watts TLP. Assessing periodontal health and disease. In: Periodontics in Practice: Science with Humanity. New York, NY: Informa Healthcare; 2000:33-40.

• 12. Williams CHM. Some newer periodontal findings of practical importance to the general practitioner. J Can Dent Assoc. 1936;2:333-340

• 13. Birek P, McCulloch CAG, Hardy V. Gingival attachment level measurements with an automated periodontal probe. J Clin Periodontol. 1987;14(8):472-477.

REFERENCE

• 14. Gibbs CH, Hirschfeld IW, Lee JG, et al. Description and clinical evaluation of a new computerized periodontal probe-the Florida Probe. J Clin Periodontol. 1988;15(2):137-144.

• 15. Zhou H, McCombs GB, Darby ML, et al. Sulphur by-product: the relationship between volatile sulphur compounds and dental plaque-induced gingivitis. J Contemp Dent Pract. 2004;5(2):27-39

• 16. Kung RT, Ochs B, Goodson JM. Temperature as a periodontal diagnostic. J Clin Periodontol. 1990;17(8):557-563

• 17. http://www.dentistryindia.net/content/DI/img/2009/05

REFERENCE• 18. Rams TE, Slots J Comparison of two pressure-sensitive

periodontal probes and a manual periodontal probe in shallow and deep pockets.Int J Periodontics Restorative Dent. 1993 Dec;13(6):520-9.

• 19. L. Mayfield*,  G. Bratthall,  R. AttStröm Periodontal probe precision using 4 different periodontal probes Journal of Clinical Periodontology23;(20)76–82, February 1996

• 20. Garnick JJ, Silverstein L Periodontal probing: probe tip diameter.J Periodontol. 2000 Jan;71(1):96-103.

• 21. Crit Rev Oral Biol Med. Periodontal probing. 1997;8(3):336-56. Hefti AF.

REFERENCE

• 22. Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation Jill S. Nield-Gehrig.pg 226-227

• 23. Parakkal PF. Proceedings of the workshop on quantitative evaluation of periodontal diseases by physical measurement techniques. J Dent Res. 1979;58(2):547-553

• 24.Armitage GC,Svanber G K,Loe H,Microscopic evaluation of clinical measurements of connective tissue attachment levels J clin Periodontal 1977;4 173-190.