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Periodontal Probing: Probe Tip Diameter*

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Periodontal Probing: Probe Tip Diameter* PeriodontalProbing: Probe Tip Diameter* Jerry J. Garnick and Lee Silverstein Background: Periodontalprobing is one of the most In diagnosing and evaluating treatment of peri- common methods used in diagnosing periodontal dis- odontal diseases,the presenceof inflammationand ease-The purpose of this studg was to determine the subsequentpathologic changes of the periodontium Importance of the diameter of periodontal probing tips are evaluatedby various means, including inflam- in diagnosing and eualuating periodontal disease. mation,presence of bacteria,gingival crevicular fluid Nlethods: The literature discussing periodontal flow, and periodontalprobing. These methods demon- probe diameters in human, dog, and monkeg stud- strate a lack of sensitivityand objectivity to be totally ies was reuiewed and compared. Tip diameters uar- reliablecriteria for clinicians.As a result, there has ied from 0.4 to ouer 1.0 mm in these studies. Probe been researchinterest in these methods with the goal adoancement between the gingiua and the tooth is of improving the ability to evaluateperiodontal dis- determined bg the pressure exerted on the gingiual eases.Clinicians can estimatethe severityof inflam- trssuesand resistancefrom the healthg or inflamed mation and morphologicalchanges caused by past trssue. The pressure is directLg proportionate to the periodontal disease but are not able to determine force on the probe and inuerselgproportionate to the ongoing and potentialtissue destruction using exist- probe tip diameter. The larger probing diameters ing diagnostictechniques. 1'2 reduced probe aduancement into inflamed connec- Currently,periodontal probing depth (PD), loss of tiue tissue. This effect of change tn probe diameter connectivetissue attachment, and bleedingon prob- reduced the pressure in a greater manner than an ing are generallyused to estimateseverity of inflam- increase of similar change in probe force. mation and responseto treatment.Evaluation of these Results.' ln the studies reuiewed, the pressure used parametersdepends on the use of the periodontal to place the probe tip at the base of the periodontaL probe. Therefore, there has been considerable sulcus/pocket was approximatelg 50 N/cm2 and at researchinterest in the mechanicsand functionsof the base of the junctional epithelium, 200 N/cm2. A the probe in order to improve its effect. tip dtameter of 0.6 mm LDasneeded to reach the base A brief description of periodontal probing is of the pocket. Clinical infLammation did not neces- important for this review. The periodontist places sari"Lgreflect the seueritg of histological inflammatton, the probe into the sulcus or clinical pocket and and the recordings mag not illustrate probing depth. applies a force to move it apically into the tissue Furthermore, probing depth did not identifg anatom- along the tooth surface.The clinician applies pres- ical locations at the base of the pocket. sure on the tissue and when the tissue exerts an Conclusions: Probe tips need to haue a diameter oppositeequal pressureto the probe, displacement of 0.6 mm and a 0.20 gram force (50 N/cm2) to obtain of the probe into the tissue will cease. The pres- a pressure which demonstratesapproximate probing sure exertedby the probe is directly proportionalto depth. This pressure uas needed to measure the the force on the probe and inverselyproportional to reduction of clinical probing depth, which included the area at the probe tip (pressure= Force applied formation of a long junctional epithelium as a resuLt on the probe/areaat the tip end =F/pr2 =Fllt(d/2)2; of therapg. In addition, different forces or diameter r = radius, d : diameter).With a round probe, a tips are needed to measure healthg or inflamed his- change in the tip diameter has a greater effect on tological periodontal probing depths. J Periodontol pressurethan does a similar changein the force. An 2000:71:96-103. increasein the probing force will increasethe pres- sure by a proportionalamount. However,a rela- KEY WORD$ tively similar increaseof the probe diameter will Periodontalprobes; dental instruments; reduce the pressureby a proportional amount which periodontal diseases/diagnosis. is squared. If the force is doubled (20 to 40 gram force), the pressureis increasedby a factor of 2. lf the diameteris doubled(0.4 to 0.8 mm), the pres- sure is reduced by a factor of 4. It, therefore,is * School of Dentistry, Medical College of Georgia, Augusta, GA. important that in discussionson the use of a peri- 96 Volume 7l . Number I Periodontol . 2000 Marini, Checchi, Vecchiet, 30. Gillam DG, Bulman JS, Jackson RJ, Newman HN. Com- Send reprint requests to: Dr. Ida Marini, Via Sant'Angela parison of 2 desensitizingdentifricies with a commer- Merici 60, 25723 Brescia, Italy. cially available fluoride dentifrice in alleviating cervical dentine sensitivity.J Peri.odontol1996;67 :737 -7 42. Accepted for publication June 2, 1999. 31. Blomlof J, Jansson L, Blomlof L, Lindskog S. Root sur- face etching at neutral pH promotes periodontolhealing. J CItn Periodontol1,996:23:50-55. 32. Ingram G, Nash PF. A mechanism for the anticaries action of fluoride.Carles Res 1980;14:298-303. 33. Ten Cate JM, FeatherstoneJDB. Physico-chemical aspectsof fluoride-enamelinteractions. ln: FejerskovO, Ekstrand J, Aburt B, eds. Fluoride in Dentistrg. Copen- hagen: Munksgaard; 1996:252-272. 34. Fejerskov O, Johnson NW, Silverstone Liv\. The ultra- structure of fluorosed human dental enamel. Scand J Dent Res 1974;82:357 -37 2. 35. Fejerskov O, Josephsen K, Joost Larsen M, Thylstrup A. Cytological feature of rat ameloblastsfollowing long- term fluorideexposure. Caries Res 1980;14:181-182. 95 odontal probe, both the force and the probe diam- the diagnosticchart. He used a medium-thickness eter (or pressure in N/cm2) are examined in order silver abscessprobe or a scaler,with a blunt blade. to reach valid judgments and comparisons. With In the late 1950s,Goldman et aI.,9Orban et a|.,10 tissue inflammation, resistance to the probe is and Glickmanll publishedtheir texts on periodontal reduced so that the probe with the same pressure diseases.All authors agreed on the importance of will penetrate deeper into the tissue until a similar the periodontalprobe in diagnosis,prognosis, and opposing tissue pressureis reached.lf the clinician treatment and supported use of the Williams probe uses a probe tip with a reduced diameter,the pres- which was rod-shapedwith 7, 2, 3, 5, 7, B, and 9 mm sure will increase and the probe tip will penetrate markings,and a 1.0 mm diameter at the tip.i5't6 much deeper into the same inflamed tissue. Goldman et al.e stated that "Clinical probing with Becauseof the great effect on probing displace- suitableperiodontal instruments such as the Williams ment, variationsin probe diameter are important. The calibratedprobe is a prime necessityin delineating purpose of this report is to review the literature on the depth, topography and character of the peri- probe diametersand discusstheir importancein the odontal pocket." Glickmanl l stated that "The pocket use of periodontalprobing. probe is an instrumentwith a taperedrod-like blade which has a blunt and roundedtip." Thesetwo clas- EARLYPERIODONTAL PROBE DESIGNS sic publicationsemphasized the use of the probe and Observationsof clinical inflammationof the gingiva not its configuration;furthermore, the diameter or and bone loss in radiographshave been used for force was not consideredimportant. Probingwas con- many years for the diagnosisand treatmentof peri- sideredto measurethe depth of the "histological odontaldiseases. In 1915, Black statedthat flat peri- pocket." odontal probes, 15 mm long with markings every During this period, the rationalefor using a peri- mm, should be used in examinationof clinicalpock- odontalprobe became accepted as part of the exam- ets presentin periodontaldisease and beforesurgery.3 ination for periodontaldiseases.lT'18 1t't addition, the He recommendedthat the level of the pocket fluid on parameters for the periodontal probe as presented the probe tip be read to determinethe clinicalpocket by Ramfjordin 19594became accepted as the norm. depth. Probes were used at baseline examinations However,there was little researchsupporting these and before surgery. He did not recommend a probe parameters.Tibbetts indicated that determination of tip diameter or probing force. PD in exact millimeter measurementswas impor- The probes most commonly used today were tant.19Among the probeshe reviewedwere the Mer- developedby Ramfjordin 1959.4He statedthat the ritt, Williams,Michigan, and Gilmore (round) and probes in use at that time were too thick to probe Goldman-Fox, Drellich, and Nabers (rectangular). narrow clinical pockets and designeda round probe Neitherthe Merritt or Gilmore probes are calibrated. with a tip diameterof 0.4 mm. This diameterof the The University of Michigan probe had 3, 6, and B periodontalprobe was acceptedas the standard. mm calibrations;the Drellich probe had 4,6, B, and Before Ramfiord's publication, investigators were 10 mm markings; and the Williams, Goldman-Fox, divided regardingthe value of periodontalprobes in and Nabor probeswere marked in 1 mm increments the examination, diagnosis,and prognosis of peri- with 4 mm and 6 mm deleted to facilitate reading. odontal diseases.Between 1915 and 1958, several Again, the diameters of the round tip probes were reports supported use of the periodontal probe to not emphasized.In 1967, Clavind and Loe reported determinethe diseasestatus of gingival tissues.5-11 the resultsof
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