DIAGNOSING Your DIAGNOSTIC Probes CALIBRATE YOUR TEAM to ENSURE ACCURATE READINGS

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DIAGNOSING your DIAGNOSTIC probes CALIBRATE YOUR TEAM TO ENSURE ACCURATE READINGS

BY GREGORY E. OXFORD, DDS, MS, PhD

As the population of the Unites States odontal status.4 similar reliability in the measurement of ages, we have a greater percentage of pa- Periodontal probes have undergone untreated periodontitis.4 tients retaining more teeth. The desire extensive changes since their introduc- Consequently, general practitioners to remain actively engaged as we age has tion by G. V. Black.5 The periodontal probe and dental hygiene professionals should led to an increasing desire to maintain a has evolved from a unidimensional, first- feel comfortable that they are operating healthy, functional dentition. The major generation manual probe into a more so- within the standards of care using a stan- cause of tooth loss in adults is periodontal phisticated computerized instrument. dard manual periodontal probe. diseases.1 The evaluation of the periodon- In an effort to increase the accuracy tal health status of our patients is very and reproducibility of readings and to ACCURACY IS KEY important. improve efficiency, Michigan “O” probe The importance of the accuracy of our At the present time, the diagnosis and was introduced by Ramfjord6 and was probing, irrespective of our choice of in- classification of periodontal diseases are followed by the development of the pres- strumentation, is that we use these mea- almost entirely based on clinical assess- sure-controlled second-generation probes surements for the diagnosis and classifi- ments. Clinical probing depths and mea- with visual measurement recordings to cation of our patients’ periodontal status. surements of attachment loss obtained reduce probing error. Third-generation, There is significant evidence of our less- with periodontal probes are a practical controlled-force electronic periodontal than-perfect reliability of clinical param- and important method of determining a probes with direct computer-linked data eters we obtain and use for the classifica- patient’s periodontal status.2 In fact, the capture are commercially available and tion, or misclassification, of periodontitis American Academy of Periodontology are currently in use by some practitio- in our patients.9 As a result, we need to use (AAP) states that part of a comprehensive ners.7 Fourth- and fifth-generation probes the best probe for each indication. periodontal evaluation should include are already being developed. An experi- Periodontal probes are used to assess probing depths, location of the gingival mental periodontal probe incorporating the health of the periodontium, for either margin (for determination of clinical at- optical fiber sensor to tap into technologi- screening purposes or to evaluate peri- tachment levels), and the presence of cal advances to help us be more accurate odontal changes throughout a treatment bleeding on probing.3 in our assessment of our patients’ disease process. For instance, a WHO (World Supplemental quantitative and quali- status is an example.8 Health Organization) probe may be an ap- tative assessments of gingival crevicular The selection of a periodontal probe propriate instrument to use for screening fluid and subgingival microflora can po- depends on the type of dental practice patients in a general practice, but would tentially provide useful information about in which it will be used. For example, a be less useful when evaluating changes the etiology or treatment approach for a general dental practitioner would require in periodontal status during active peri- particular patient’s periodontal disease. first- or second-generation probes, while odontal therapy. However, probing depth and clinical at- third- through fifth-generation probes Therefore, each probe has character- tachment loss measurements obtained generally are used in academic and re- istic features that make it unique and, in with manual periodontal probes remain search institutions as well as specialty some cases, specific and limited in use. the primary method used to assess the practices. Cochrane meta-analysis of The AAP parameters of care3 state that status of the periodontium and are a prac- different periodontal probing studies re- evaluation of probing depths and furca- tical and valid method for assessing peri- vealed manual and electronic probes have tion involvements are important in appro-

Fig. 1 priate and accurate diagnosis of the patient’s periodontal disease status. Thus, we need to use the correct probe to accurately assess the patient’s unique periodontal condition. Your armamentarium may include a variety of instruments with their unique, familiar charac- teristics. You should choose your probe based on your objective. For instance, a diagnostic tray may include a periodontal probe for probing depths, another probe for furcation probing, and, in many cases, a plastic probe for dental implant probing. When selecting a probe for measuring pocket depth, you should consider selecting a probe that has markings that you are familiar with. Some examples of common markings are shown Fig. 2 in Figure 1.

Your entire clinical team should consider using the same probe design to aid in the calibration and accuracy of your measurements. For probing depth measurements, use a probe with discrete millimeter markings to increase accuracy and support calibration. For example, consider newer probe designs with discrete markings such as a UNC12 or UNC15 probe rather than the Mar- quis 3-6-9-12 design markings when measuring probing depths, recession, and clinical attachment levels as this may be more accurate10 (see Figure 2). Additionally, the accuracy in the production of periodontal probes from commercially available periodontal probes has Fig. 3 been evaluated for millimeter marks and probe tip diameter standardization. Hu-Friedy periodontal probe marks in one comparative study were found to be more accurately manu- factured.11 The accuracy of probing depths is also greatly affected by a multitude of factors such as probe type and design,12,13 location and angulation of the probe, pressure of probing,14 presence of calculus and restorations, inflammation, malaligned teeth, etc.15 The use of specific typodont models to calibrate within an office is useful for clinician training prior to use, facilitating ac- Using a typodont to calibrate intra-office clini- curacy (see Figure 3). cians Another means of achieving more intra-office reliability is to limit the clinicians who take the probing measurements. For example, the hygiene team members in our practice perform and does not measure furcation entrance distance in millime- probings as part of their routine maintenance therapy; however, ters but rather by the subjective evaluation of the degree of at- the periodontist completes a full-mouth probing annually for tachment loss through the furcation. patients of record. This limits inter-examiner variability and Alternatively, Hamp et al.17 measure the degree of furca- may allow for less variability and more accuracy. tion involvement by the millimeters which the probe enters When measuring furcation involvements, select a furcation into the furcation system. Consequently, if using Hamp for probe based on the furcation classification system that you are furcation measurements, it would require the use of a probe using in your office. The most widely used furcation measure- that allows measurements in millimeters as shown in Figure ment or grading system was described by Glickman.16 Glickman 4. Again, consistency within the practice provides more reli- grades degree of furcation involvement on a scale of zero to four ability and accuracy. DIAGNOSING YOUR DIAGNOSTIC PROBES

Fig. 4 Periodontal probing of soft 2. Armitage GC. Research and Science Ther- tissue depths, furcations, and apy Committee of the American Academy of Periodontology. Diagnosis of periodontal dis- around dental implants with eases. J Periodontol 2003 Aug; 74(8): 1237-47. manual probes remains the 3. Parameter on Comprehensive Periodontal mainstay of our clinical diag- Examination. J Periodontol 2000 May (Supple- ment); 71: 847-8. nostic methods. The future of 4. Neiderman R. Manual and electronic disease diagnosis is, however, probes have similar reliability in the measure- on the cusp of changing and ment of untreated periodontitis. Evid Based Dent 2009; 10(2): 39. may utilize many technologi- 5. Black GV. The fibers and glands of the cal advances. periodontal membrane. Dental Cosmos 1899; One such advance is the 41: 101-122. 6. Ramfjord S. Indices for prevalence and in- emergence of probes that cidence of periodontal disease. J Periodontol assess periodontal disease 1959; 30: 51-9. activity noninvasively with 7. Breen HJ, Rogers PA, Lawless HC, Austin JS, Johnson NW. Important differences in clinical subtraction radiography to data from third, second, and first generation IMPLANT MEASUREMENTS evaluate quantitative and qualitative periodontal probes. J Periodontol 1997 Apr; When selecting a probe for measuring changes in periodontal architecture even 68(4): 335-45. 8. Ishihata K, Wakabayashi N, Wadachi J, Aki- pocket depth around a dental implant, you before clinical changes are evident. Many zuki T, Izumi Y, Takakuda K, Igarashi Y. Reproduc- should select a plastic probe. Dental im- of the logistical problems associated with ibility of probing depth measurement by an plant surfaces are typically titanium and subtraction radiography are being over- experimental periodontal probe incorporating an optical fiber sensor. J Periodontol 2012 Feb; can be easily scratched or nicked, produc- come, and this powerful diagnostic tool 83(2): 222-7. ing surface irregularities that may provide may soon come into widespread use. 9. Corraini P, Lopez R, Vaeth M. Implications of a foundation for bacterial attachment. Future developments in this and other less-than-perfect reliability of clinical parameters for the misclassification of periodontitis. The AAP standards of care regard- imaging techniques are likely to have a Community Dent Oral Epidemiol 2015; Jan 27. ing periodontal maintenance of dental profound effect on our approach to the 10. Holtfreter B, Alte D, Schwain C, Desvarieux implants states that implant manage- diagnosis of periodontal diseases. Until M, Kocher T. Effects of different manual periodontal probes on periodontal measurement “must have periodic evaluation of then, probe on. But do it judiciously and ments. J Clin Periodontol 2012 Nov; 39(11): implants, surrounding tissues and oral with a well-calibrated team and well-cali- 1032-41. hygiene are vital to the long-term success brated instruments. RDH 11. Neto JB, Filho GR, Tramontina VA, Sallum EA, Nociti FH Jr, Sallum AW. Millimeter marks of the dental implant. Considerations in and probe tip diameter standardisation from the evaluation of the implant are: pres- GREGORY E. OXFORD, DDS, MS, PhD, is a board- commercially available periodontal probes. ence of plaque/calculus; clinical appear- certified periodontist, implant and dental A comparative study. J Intl Acad Periodontol surgeon in Florida with a clinical as well as 2001 Jul; 3(3): 57-60. ance of peri-implant tissues; radiographic research background. He has authored and 12. Buduneli E, Aksoy O, Köse T, Atilla G. Ac- appearances of implant and peri-implant delivered numerous reports on both clinical curacy and reproducibility of two manual periodontal probes. An in vitro study. J Clin structures; occlusal status, stability of and scientific aspects of periodontics. He is a Periodontol 2004 Oct; 31(10): 815-9. recognized expert and lecturer in the field of prostheses and implants; probing depths; 13. van Weringh M, Barendregt DS, Rosema presence of exudate or bleeding on prob- periodontology of national and international NA, Timmerman MF, van der Weijden GA. A acclaim. He was the 1998 recipient of the ing and modification of maintenance in- thin or thick probe handle: does it make a dif- prestigious American Association for Den- ference? Int J Dent Hyg 2006 Aug; 4(3): 140-4. 18 terval as needed.” tal Research (AADR) Periodontal Research 14. Al Shayeb KN, Turner W, Gilliam DG. Accu- Clearly, there is a need to probe around Award, the Bill Clark Research Fellowship, as racy and reproducibility of probe forces during dental implants. The common practice to well as a recipient of the American Academy simulated periodontal pocket depth measure- of Periodontology (AAP) Partners in Practice ments. Saudi Dent J. 2014 Apr; 26(2): 50-5. minimize probing of dental implants is 15. Al Shayeb KN, Turner W, Gilliam DG. Peri- Periodontal Research Award. Dr. Oxford acts odontal probing: a review. Prim Dent J 2014 also appropriate. Be cognizant that the soft as a consultant for several companies as well tissue attachment of periodontal tissues to Aug; 3(3): 25-9. as the University of Florida and State of Florida 16. Glickman I. Clinical Periodontology. WB the implant is significantly different than Board of Dentistry. Saunders Company, Philadelphia, PA 1953 to a tooth. As a result, repeated probings Chapter 26; 597-8. around a dental implant is discouraged. REFERENCES 17. Hamp SE, Nyman S, Lindhe J. Periodontal treatment of multirooted teeth. Results after 5 1. Eke PI, Dye BA, Wei L, Slade GD, Thornton- Get in, measure, and get out when the situ- years. J Periodontol 1975 Aug; 2(3): 126-35. Evans GO, Borgnakke WS, Taylor GW, Page RC, 18. Parameter on Placement and Manage- ation is healthy, but probe if you must. The Beck JD, Genco RJ. Update on prevalence ment of the Dental Implant. J Periodontol 2000 frequency of probings is less clear and is of periodontitis in adults in the United States: May (Supplement); 71: 870-2. more a factor of the clinical evaluation of NHANES 2009-2012. J Periodontol 2015 Feb; 17: 1-18. the peri-implant soft tissues. LAY THE FOUNDATION FOR THE BEST CLINICAL OUTCOMES

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