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       2

       EXAMINATION AND DIAGNOSIS

       Shan-Huey Yu, DDS, MS

      DEFINITIONS AND TERMINOLOGY

Clinical attachment level: The distance from the cementoenamel junction (CEJ) to the tip of a periodontal probe during periodontal diagnostic probing. The health of the attachment apparatus can affect the measurement.¹

      Furcation: The anatomical area of a multirooted tooth where the roots diverge.¹

      Furcation involvement: Pathologic resorption of bone within a furcation. The degree of interradicular bony destruction of a multirooted tooth. It is characterized by factors such as root trunk length, root concavities, and the extent of root separation.²

      Recession: The migration of the marginal soft tissue to a point apical to the CEJ of a tooth or the platform of a dental implant.¹

      A thorough and comprehensive clinical and radiographic examination is the critical first step for establishing a proper periodontal diagnosis before a treatment plan can be developed. The objective of this chapter is to review the main components of a periodontal examination and interpretation of these parameters to aid in developing a periodontal diagnosis. The second part of this chapter is an overview of the different classifications for periodontal diseases and conditions that have been proposed and developed over the years.

      Clinical Examination

      To determine a proper periodontal diagnosis, clinicians should perform a periodontal examination that includes but is not limited to the following parameters^2,3:

       Probing depth (PD)

       Gingival recession

        Clinical attachment level (CAL)

       Width of keratinized gingiva (KG) and attached gingiva (AG)

       Signs of gingival inflammation (ie, bleeding on probing [BOP], suppuration, gingival color and texture)

       Tooth mobility

       Degree of furcation involvement

       Extent, distribution, and pattern of radiographic bone loss

       Patient’s medical and dental history3

      PROBING DEPTH

      The measurement of PDs is considered to be one of the most important parameters of the periodontal examination because it provides an overall assessment of the periodontal pockets, which are usually considered as a critical sign for the establishment of a diagnosis. In addition, pockets are also the major habitats for periodontal pathogens.³ Currently, the most widely used instrument to obtain PDs in clinical practice is the conventional or manual probe. In 1936, periodontist Charles H. M. Williams created the first periodontal probe, and his invention—the Williams periodontal probe—has been the prototype or benchmark for all manual probes.⁴ Different types of conventional periodontal probes have been developed over the years and utilized for different indications. Box 2-1 summarizes the common types of conventional probes used in the clinic and their characteristics and indications.⁴

BOX 2-1 Common types of periodontal probes

       Williams probe

       The graduations on this probe are 1-, 2-, 3-, 5-, 7-, 8-, 9-, and 10-mm. The 4- and 6-mm markings are absent to improve visibility and avoid confusion in reading the markings.

       Merritt B probe

       The graduations and markings on this probe are the same as Williams probe.

       Goldman-Fox probe

       This probe has a flattened tip. The graduations and markings on this probe are the same as Williams probe; however, the flat tip end might preclude easy access into tight or narrow pockets.

       UNC 15 probe

       The graduations on this probe are 1-, 2-, 3-, 4-, 5-, 6-, 7-, 8-, 9-, 10-, 11-, 12-, 13-, 14-, and 15-mm. This probe is color-coded at every millimeter demarcation, and it is suitable for deeper pockets (ie, > 10 mm).

       Marquis color-coded probe

       The graduations on this probe are 3-, 6-, 9-, and 12-mm. Color markings are darker at 3–6 mm and 9–12 mm. The main disadvantage of this probe is its accuracy; the measurements are usually estimated between color markings.

       Michigan O probe

       The graduations on this probe are 3-, 6-, and 8-mm and are color-coded. This probe might not be suitable for deeper pockets (ie, > 8 mm), and the measurements are also estimated between color markings.

       CPITN probe

       The graduations on this probe are 3.5-, 5.5-, 8.5-, and 11.5-mm. Markings are a darker color at 3.5–5.5 mm and 8.5–11.5 mm. This probe is particularly useful for screening and monitoring patients or for epidemiologic research.

      UNC, University of North Carolina; CPITN, community periodontal index of treatment needs.

      Conventional probes are easily operated and inexpensive; therefore, these are the most commonly used probe system in dental clinics. However, conventional probes also present with several disadvantages⁴:

       The pressure applied cannot be standardized.

       Assistants are often needed to transfer measurements