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 Importance of the diameter of periodontal probing tips are evaluatedby various means, including inflam- in diagnosing and eualuating . 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 , 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 proportional amount. 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 , 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. Probeswere 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 a researchprotocol in which they used Probespecifications, including the tip diameter,were a periodontalprobe tip that was 0.8 mm in diameter generally not indicated, nor was there any research with a 10 gram force.2o on the effect of probe design in most of these reports. Others did not support the use of periodontalprob- Measure of Clinical Pockets bg Probing ing, but rather supported radiographs in the diagno- The general interpretation of periodontal probing is sis of the periodontaldiseases.l2-14 that the probe measuredthe pocket depth, which was Simonton5proposed flat probes 1 mm wide, 10 similar to the histologicaldepth. Therefore,by doc- mm long, and notchedevery 2 mm. Box6 used spe- umenting the amount of displacement of the probe cial gold or silver probes that had 5 different angu- into the tissues, changes in probing depth could be lations. Miller/ suggesteciprobing of all pockets and measured. Ramfjordasuggested the use of a modi- recording their depth and putting this information on fied Williams probe,with a diameterof 0.4 mm, which

J Periodontol. January2000 ffarnick.$ilverstein 97 could measurenarrow pockets,rather than the orig- in pressure become important in the understanding inal 1.0 mm. The effectsof this cross-sectionalmod- of probing. ification on probe penetrationwere not studied. These resultswere supportedby studies in dogs However,published reports demonstratedthe dif- and humansusing periodontalprobes. Sivertson and ficulty of measuring the histological pocket depth. Burgett found that the thin Marquis (Hiatt) probe tip In 1960, Kohler and Ramfjord reported that the (0.4 mm diameter) extended to the coronal most sharp end of a No. 2 silver point (0.2 mm diame- attachmentand through the junctional epithelium.26 ter) was utilized to measure tissue changes,and Other studiesreported similar results.27,28lt must be probed deeper in areas of anesthesia.2lThe sharp realizedthat even though forces used were low, pres- pointed probe was not recommended for measur- sures exerted by the probe were very high because ing PD, and it was recommendedthat PD should be thin probes were used; and penetrationof tissueswas measured before anesthesiawas induced. At this deep. same time, 3 reports22-24demonstrated that 0.1 to 0.5 mm thick steelblades or celluloseacetate strips RETATIONSHIPOF PROBEPRESSURE, FORCE, penetrated beyond the base of the sulcus and into PIAMMTMR,ffi INGIVAL MORPHOLOGY,ANN the junctional epithelium. Zander23placed a cellu- INFLAMMATIONTO PROBEDISFLACEMENT lose acetatefilm 0.1 mm thick into the sulcusof a Listgarten summarizedthe published results by stat- young dog, with a very slight amount of force. The ing that "probing depth measuredfrom the gingival photomicrographsdemonstrated the location of the margin seldom correspondedto histologicalsulcus strip outside and within the junctional epithelium. or pocket depth. The discrepancy was less in the The strip was still wider than the junctionalepithe- absenceof inflammatory changes and increasedwith lium; therefore,resistance was by collagenfibers. increasingdegrees of inflammation.Following treat- The strip endedjust coronal to the base of the junc- ment, decreasedprobing depth measurementsmay tional epithelium. In one part of their dog study, be due in part to decreasedpenetrability of the gin- Orban et a1.24used a steel blade, 0.5 mm thick gival tissues."2eThe location of the probe tip depends and 1 mm wide. With a light force they could probe on the pressureapplied and resistanceof the tissue. 1 mm deep; with an increasedforce they could The probe has greater penetration of tissues with probe 1.5 mm. The probe was slightly apical to the increasing pressureon the probe, and the resistance sulcus but still adjacent to the junctional epithe- varieddepending on tissuecharacteristics, morphol- lium. Again, this blade was wider than the junc- ogy, andlor tissue inflammation. In general, the use tional epithelium. The result, however,also indi- of the periodontal probe resulted in over-probing of cated that probing for histological pocket depth the histologicalpocket or sulcus. was difficult and that using thin probes results in van der Veldenand Jansen describedthe differ- excessive probing. ent parameters associatedwith probe movement. Probingdepth measuredboth the histologicalsulcus/ They indicated that the pressureapplied to the probe pocket and the junctionalepithelium. The junctional moved the probe along the tooth until an opposing epithelium was 15 to 30 layers thick; each cell is pressureprevents further movement.30 The pressure approximately6 pm or 0.006 mm wide,25which com- was equal to force/area at the end of the probe tip putes to a thicknessof 0.09 to 0.18 mm. This width and is stated in terms of N/cm2. If the diameter of is too narrow even for the thin Michigan periodontal the probe tip is standardized,such as 0.6 mm, the probe (0.4 mm) to penetrate without involving the change in pressurewill be directly proportional to adjacent connective tissue. In general, these studies the change in force applied on the probe. The dis- indicated that probing performed with thin probes placement of the probe will then depend on the force (0.1 to 0.5 mm) over-probedthe sulcusand extended on the probe and the tissue resistance.3l Typical to the base of the junctional epithelium, and that force-displacementcurves can then be generated the connective tissue adjacent to the sulcus wall was (Fig. 1). Inflammationreduces the ability of the tis- a major factor in probe resistance.Therefore, the sues to exert pressureopposing that exerted by the probing instrument did not measure morphologic probe, resulting in greater tissue penetration (Fig. identifying locations, such as the base of the histo- 2). van der Veldenand Jansen further suggestedthat logical pocket and junctional epithelium, but mea- with a probe 0.63 mm in diameter, the optimal force sured generaltissue resistanceto the pressureplaced to probe the most coronal connectivetissue attach- on the probing instrument. Thus the factors involved ment was 0.75 N; i.e., about 240 N/cmz. Polson et

98 PeriodontalProbing; Probe Tip Diameter Volume 7l . Number I MeanProbe Advancement by Figurel, Forcelor Gontrol Sites Grophdemonstroting exomples offorce-displocement curves ot 2 subsequentprobrngs lnto o su/cusof o dogTheprobe tip diometer wos0.6 mm.The probe odvonced into the su/cus os forces were increosed,butmovement wos reduced wlth lncrecsed ttssue reslstonce,Ihere were no stotlsticd/ drff?rences between the 2 probingouempts (after Keagle JG et ol.;reference 46; reproduced withpermission). 2.0

a1.32demonstrated in humans that the periodontal c ot probe penetratedto the base of the junctional epithe- q, lium in periodontal health using 205 N/cm2. Both = 1.5 IE pressureswould reach the connectivetissue attach- E ment and not measure the formation of long junc- 6' !t tional epithelium.Garnick et aI.31estimated that ct o- pressureof 47 N/cm2 of 0.2 N, diameter 0.6 1.0 lforce mm) appliedto the probe placed the tip slightly api- cal to the coronal edge of the junctional epithelium in healthy tissues(Fig. 3). Tissue pressurethat resists probe displacement depends on tissue morphology including loss of attachmentand the severityof tissue inflammation. Clinicalinflammation does not necessarilycorrespond to tissue inflammation(Fig. 4); i.e., obvious clinical gingival inflammation may not be as severe as with histologicalinflammation. Since histologicalinflammation affects tissue resistance,the clinician may not recognizethe level of tissue resistanceto the probe. Systemic and random errors occur in periodontal probing (see reference 28 for review); this paper addresses random error. There are 4 different vari- ablesconcerned with probing,3 of which (force,tip diameter,and probe location) can be stan- dardized,but it is difficult to stan- dardize the fourth, connective "s 123456789 tissue inflammation, since it is Displocemenf(No. x .356=mm displocement) usually evaluated clinically. - L,M,Np moxilloryheolfhy olfoched gingivo Standardized probing force, tip - qQ,R,S olveolormucoso diameter,and probe location can - H,l,J moxillory inflomedofloched gingivo improve calibration.In practice, probe location is not standard- Flgure 2. ized because of the need to Groph demonstrotingchcnges in the force-displocementcurves with chongein tissueconsistency locate the most severe areas of (ottochedgngiva versusolveolor mucoso) ond with inflommatton(heolthy versus inflomed ottoched disease for treatment. However, gtngvo) in the dog. Both fodors resulted in force-displocementcurves shifiing to the righg in researchprotocols, location is t.e,,greoter tlssue penetrotion at the someforce ond probetip diometerot 0.6 mm, with chongesin standardizedin order to evaluate type of tissueond inflommotion. change of diseaseat one site.

J Periodontol. January2000 Garnick,$ilverstein 99 0

cr

c) o l!

]J (! 0) ! tr

6- rl03 ,r Prcaruac GI=0 Prc.rula (IPr) 123 Dog Number A A

ti o

ol 6

(l

! d .30 o !

6 403 h Preurc Do8 NuDber DogNumDer Prcurc (lPr) t23456 789 B B

Figure3. Figure 4" Regresslononolysis ofdoto from force-displocement curves of Crophsdemonstroting the development of clinicalgngval probtngthe gngvol sulcus of dogs.Theprobe tip wosestimoted ta tnflommotionin dogs(A) ond resultswhen the gingivci tlssues were beotthe bcseofthe suicus wrh pressuresof 47 Nlcmzft74 kPo) evoluotedhistologicolly (B). Ainicol ginglvol inflommoLion wos tn (A) ondot themost-coranol connectivetlssue ottochme nt witho chorocterizedbygngivol tndex ond gtngvol fluid flow. Histologcol pressureof 298 Nlcmt(1927 kPo) in (B).Thisdemonstroted thot voriottonswere especiolly greot in situotionsof heolthyond slighdy differentpressures resulted tn differentdegrees oftlssue penetrotion inflomed(Gl = 2) gngva(ofter Gornick lJ et ol.;refbrence 3 l). (ofterCornick lJ et ol.;reprence 3 l).

100 Period*ntal Probing: Probe Tip Dianreter Volume7l . Number I Table l. Comparisonof Probe Tip Diameters and Force in PeriodontalProbings

EstimatedForce for ProbeDiameters to MeasureHistological Sites

Diameters Baseof Sulcus Coronal Connective (mm) (P= 50 N/cm2) Tissueattachment (P = 7OON/cm2)

0,4 6gr(006N) 2sgr (0.2s N) | 05 l4 gr (0.l4 N)x 57gr (0.57 N)

Best combinations of force and probe diameters are: * 0.6 mm diameter at 20 gram force (least force in a hand-held probe) to probe the base of the sulcus and determine formation of long junctional eDithelium. f 0.4 mm diameter at 20 lo 25 gram force to probe to connective tissue attachment to determine regeneration of connective tissues but not long junctional epithelium formation. With use of a 0.6 mm diameter probe, a 20 gram force was estimated to measure sulcus depth (and long junctional epithelium formation) and 60 gram force to measure most coronal connective tissue attachment.

inflamed and less with healthy tissue. Since the probe diameter is a major factor in probing, they compared force-displacement curves for probes with different diameters in healthy, inflamed and greatly inflamed tissues. Probe diameters of 0.6 mm dis- criminated best the different levels of gingival inflam- fiigwrm .5. mation and health; probing deeper with increased Schemoticdrowing of conceptswhtch were presentedtn thisreport. E inflammation. = enomel;D = denttn;C = ;p = forceon the probe;lCT.1 = areoof tnflommattanot the bcseof the periodontolprobe; lCT, = The World Health Organization44proposed a prob- oreoof tnflommottonloterol to the probe:p= pressureof the probe ing tip with a hemispheric shape and a diameter of lnto the tissues;R = reslstonceofthe trssueto theprobe; d = dtometer 0.50 mm. lt was felt that the rounded surface would nf rha n,aho t tn P rc rlttorlh, ralnrad l^ tho fa,r o nn/1 tnd,t a.tl\ t tha ^ produce less patient discomfort. However, the effect oreoot the end of the tip.Wttho roundprobe, P = Flx(Dl2)'.Chonge tn the probettp dtometerhos o greatereffect thon chcngein E R is of this spherical configuration is not known,45 and it rlirertlt tplnle4 rn tissrtp mnrnhnlnat. i,c., 8 rnn(;(/dnl , [/55Ue may be that this shape increases the area, thus reduc- tnflammotton,cnd /ossof connectivetlssue cttcchment.The cltntcal ing the pressure. pocketdepth (probtngdepth) ls the mecsurementderived from the The periodontal probe is the major instrument used

J Periodontol. January 2000 il;;rnicli. liilvers{*in 101 Table 1;.46tf the cliniciancan apply force of approx- 4. Ramfjord SP. Indices for prevalence and incidence of periodontal imately 20 grams (0.20 N) on the periodontalprobe disease.J Periodontol1 959;30:5 1-59. 5. Simonton FV. Examination of the mouth-with special handle (in which the nail bed would not blanch),the reference to pyorrhea. J Am Dent Assoc 1925;72:287 - probe tip diameter must be increased to 0.6 to 0.7 295. mm to reduce the pressure to the level of 40 to 50 6. Box HK. Treatment of the PeriodontaLPocket. Toronto: N/cm2. At this pressure, the probe tip would be The University of Toronto Press; 1928:83. placed at the coronal end of the junctional epithe- 7. Miller SC. Oral Diagnosis and Treatment Planning. Philadelphia:P. Blakiston'sSon t' Co.; 1936:239. lium, demonstrating the formation of long junctional 8. HirschfefdI. Periodontiacase reporting. J Periodontol epithelium.a6 7946;17:74-77. 9. Goldman HM, Schluger S, Fox L. PeriodontalTherapg. CONCLUSION St. Louis: C.V. Mosby Co.; 1956:27. In summary, periodontal probing registersresistance 10. Orban B, Wentz FM, Everett FG, Crant DA. Periodon- tics, A Concept-Theorg and Practice. St. Louis: C.V. of the tissues to the pressure applied by the probe. MosbyCo.; 1958:103. This pressureis directly proportionalto the applica- 11. Glickman l. Clinical Periodontologg.Philadelphia: WB. tion of force on the probe and indirectly to the area SaundersCo.; 1958:548. of the probe tip. The greaterthe pressure,the greater 12. StillmanPR. The managementof pyorrhea.Dent Cos- is the advancement of the probe into the tissues. mos 1977:59:405-474. 13. Merritt AH. The pathology, etiology and treatment of However, the advancement depends on the resis- pyorrhea. Dent Cosmos7978;60:574-581 . tance of the tissues at the site being measured. Vari- 14. Merritt AH. Periodontal Diseases. New York: The ability in probing may result becausethe clinically MacmillanCo.; 1935:96-113. observedinflammation may not be the same as the 15. Williams CHM. Some newer periodontal findings of practical general practitioner. inflammation in the tissues penetrated by the probe. importance to the J Can Dent Assoc1935;2:333 -340. However,with treatment,if the pressureis the same 16. Williams CHM. Rationalizationof periodontalpocket but the inflammation is reduced and/or tissue attach- therapy. J Periodontol1943;14:67 -7 1. ment is increased,the resistanceis increasedand 17. Sorrin S. The Practiceof Pertodontia.New York: Mccraw the displacementof the probe will be less. The dif- Hill Co.; 1960:119. ference in probing depth would measure reduction of 18. Wade AB. Basic Periodontologg.Bristol: John Wright E Sons;1960:183. inflammation and, therefore, effectivenessof treat- 19. Tibbetts LS. Use of diagnostic probes for detection of ment. periodontal disease. J Am Dent Assoc 7967;78:549- The pressureused to measure the coronal level 555. of the connectivetissue attachmentis not the same 20. Glavind L, Loe H. Errors in the clinical assessmentof periodontal as that used to place the probe at the base of the destruction.J PeriodontRes'1967 ;2:780- 784. sulcus or the pocket, which should be much less. 21. Kohler CA, Ramfjord SP. Healing of gingival mucope- If the measurementof long junctional epithelium riostealflaps. Oral Surg OraI Med Oral Pathol 1960;1 3: and reduced sulcular/pocket depth are the objec- 89-103. tives of probing, then reduced pressuresmust be 22. WaerhaugJ. The Gingiual Pocket.Oslo: Odontol Tid- used. In this case, forces of 20 grams should be skr: 1952. 23. Zander HA. A method for studying "the epithelial used with a probe tip diameter of 0.6 mm to obtain attachment."J Dent Res 1956;35:308-312. a pressure that would measure the new sulcus 24. Orban BJ, Bhatia H, Kollar JA, WentzFM. The epithe- depth, but not penetratethe long junctional epithe- lial attachment (the attached epithelial cuff). J Peri- lium. The larger diametersthat have been used for odontol 1956;27 : 167 - 180. 25. Schroeder HE, Listgarten MA. Fine Structure of the many years, as indicated in this report, would appear Deueloping Epithelial Attachment of Human Teeth. appropriate. Basel,Switzerland: S. Karger; 1971. 26. Sivertson JF, Burgett FG. Probing of pockets related RFFFRENCES to the attachment level. J Periodontol 1976;47:281- 1. GreensteinG. Contemporaryinterpretation of probing 286. depthassessments: Diagnostic and therapeuticimpli- 27. RobinsonPJ, Vitek RM. The relationshipbetween gin- cations.A literaturereview. J Periodontol7997 ;68:1 194 - gival inflammation and resistance to probe penetra- 1205. tion. J Periodont Res 1979;14:239-243. 2. Armitage QC. Periodontaldisease: Diagnosis. Ann Pei- 28. Hefti AF. Periodontal probing. Crit Reu Oral DioI NIed odontol 1996;7:37 -215.3. 1997:8:336-356. 3. Black GV. SpecialDentalPathologg. Chicago: Medico- 29. Ustgarten MA. Periodontalprobing: What does it mean? DentalPublishing Co.; 1915:207,372. J CIin PeriodontoL798Ot7 :7 65 - 176.

102 Periodontal Frobing: Probe Tip Diameter Volume7l . Number I 30. van der VeldenU, Jansen J. Microscopic evaluationof 43. KeagleJG, GarnickJJ, SearleJR, King CE, MorsePK. pocket depth measurements performed with six dif- Cingival resistanceto probing forces I. Determination ferent probingforces in dogs. J Clin Periodontol1981;8: of optimal diameter.J Periodontol1989;60:167-171. 107-116. 44. Bulthus HM, BarendregtDS, Timmerman MF, Loos 31. Qarnick JG, KeagleJG, SearleJR, King GE, Thomp- BG, van der VeldenU. Probe penetration in relation to son WO. Gingival resistanceto probing forces. ll. The the connective tissue level: Influence of time, shape, effect of inflammation and pressure on probe dis- and probing force. J Clin Periodontol 1998;25:417- placement in beagle dog .J Periodontol1989; 423. 60:498-505. 45. Sanderink RBA, Mormann WH, Barbakow F. Peri- 32. PolsonAM, Caton JG, YeapleRN, Zander HA. Histo- odontal pocket measurementswith a modified plast- logical determinationof probe tip penetrationinto gin- 0-probe and a metal probe. J Clin Periodonfol1983;10: gival sulcus of humans using an electronicpressure 11-21. sensitive probe. J CIin Periodontol7980;7:479-488. 46. Keagle JC, Garnick JJ, Searle JR, Thompson WO. 33. Kalkwarf KL, Krejci RF. Effect of inflammationon peri- Effect of gingival wall on resistanceto probing forces. odontal attachment levels in miniature swine with J Clin Periodontol 7995;22:953-957 . mucogingival defects.J Periodontol1983;54:361 -364. 34. Claffey N, ShanleyD. Relationshipof gingivalthickness Send reprint requeststo: Dr. Jerry J. Garnick, Medical Col- and bleeding to loss of probing attachment in shallow lege of Georgia,School of Dentistry,Augusta, GA 30912- sites following nonsurgical periodontal therapy. J C/in 1220. Periodo ntol 1986 ;13:654 - 657 . 35. Claffey N, Loos ZB, GantesB, Martin M, EgelbergJ. Acceptedfor publicationDecember 22, 1998. Probing depth at re-evaluationfollowing initial peri- odontal theiapy to indicatethe initial ,"rptnre to treat- ment. J Clin Periodontol'1989;76:229-233. 36. MombelliA, MuhleT, Frigg R. Depth-forcepatterns of periodontal probing. Attachment gain in relation to probing force. J CIin Periodontol1992;19 :295-300. 37. BaderstenA, Nilveus R, Egelberg J. Effect of nonsur- gical periodontaltherapy. Il. Severly advancedperi- odontitis. J CIin Periodontol1984;7 1 :63-7 6. 38. Mombelli A, Graf H. Depth-force patterns in periodon- tal probing. J Clin Periodontol 1986;13:126-130. 39. Watts TLP.Visual and tactile observationalerror: Com- parativeprobing reliabilitywith recessionand cemen- toenamel junction measurements.Communtty Dent OraI Epidemiol 7989;77:310 -312. 40. Lang NP, Corbet EF. Periodontaldiagnosis in daily practice. Int Dent J 7995;45:3-15. 41. Breen HJ, Rogers PA, Lawless HC, Austin JS, John- son NW. Important differences in clinical data from third, second and first generation periodontal probes. J Periodontol1 997 ;68:335-345. 42. Barendregt DS, van der Velden U, Reiker J, Loos BG. Clinicalevaluation of tine shapeof 3 periodontalprobes using 2 probing forces. J Clin Periodontol 7996;23:397- 402.

. J Periodonml January2000 earniek. Silverstein 103 Chronicfilcerative Stomatitis: A CaseReport

EduardoR. Lorenzana,*Terry D. Rees,f Marcia Glass,l and Jeffrey G. DetweilerS

B ack g round: Certain mucocutaneous diseasespre- Many skin diseasesmay presentwith painful,ulcer- sent with painful, ulceratiue,or erosiueoral manifes- ative, or erosive oral manifestations.These diseases tations. Chronic ulceratiue stomatitis ts a newlg rec- often share similar oral featuresand definitivediag- ognized disease of unknown ortgin which presents nosis is sometimes difficult. Diseasessuch as lichen clinicallg with features of desquamatiue gingiuitis. planus, cicatricialpemphigoid, and pemphigus vul- This report marks onlg the thirteenth case reported i"n garis are mucocutaneous disorders of unknown ori- the world li"terature.A reuiew of preuious reports and gin in which host antibodiesare directedtowards the studies is presented along with a reuiew of immuno- epithelium andlor its junction with the underlying fluorescence techniques critical to proper diagno- connective tissue. The presence of these antigen- sis.Thesediseases are difficult to diagnose without antibodycomplexes may induce the epithelialdesqua- the use of immunofluorescence techniques.A 54-gear- mation or erosion observedintraorally. Histopatho- old Caucasian woman presented with a 2- to 3-gear logical differentiation of these conditions is very historg of stomatitis and drg mouth. important since clinical featuresmay be similar,but Methods: Direct immunofluorescence reuealed a histologicfindings are also often inconclusive.This speckled pattern of IgG deposits in the basal one-third may be especiallytrue in early lesionsor in lesions of the epi.thelium,while indirect tmmunofluorescence in which the epitheliumhas desquamated. confirmed the presenceof stratified epithelium-spectfic ln the last few years,immunohistochemistry tech- a ntin uc lear anti.ge n (S ES - A NA ), both p athog nomo nic niques, especially direct and indirect immunofluo- for chronic ulceratiue stomatitis. rescence,have been usedto clarify diagnosis.Direct Results: The patient was successfullg treated immunofluorescence(DIF) is performed by expos- using topical corticosteroid therapg. J Periodontol ing excised lesionaltissue to antibodiesof various 20OO;77:104-111. immunoglobulins,complement, and tissuebreakdown products.In indirect (llF), KEY WORDS immunofluorescence nor- mal stratifiedsquamous epithelium such as goat or Gingivitis, necrotizing ulcerative/diagnosis; monkey esophagustissue is exposedto labeledcir- gingivitis, necrotizing ulcerative/drug therapy; culatingserum antibodiesobtained from the patient. gingivitis, desquamative/diagnosis; gingivitis, A positiveresult is indicatedif the labeled antibody desquamative/drugtherapy; immunofluorescence binds with a tissueantigen. To date, distinctDIF fea- techniques. tures have been identified for lichen planus, pem- phigoid, and the various forms of pemphigus.l-4 Although only pemphigusis associatedwith consis- tent positiveIIF findings,a limited number of reports have described a lichen planus specific antigen (LPSA) which, in one study, was found in B0% of patientswith lichen planus.5.6Others have reported the "string of pearls" phenomenon using IIF which has been linked with lichenoid reactionsto certain medications.T Recently,a distinct new disease entity, chronic ulcerativestomatitis (CUS), has been describedin a limited number of case reports.8-13CUS resembles erosive lichen planus or oral discoid lupus erythe- matosusin its clinical and histologicmanifestations.

* Currently,private practice, San Antonio,TX; previously,Baylor College Therefore,it is best diagnosedvia immunofluores- of Dentistry,Texas A and M UniversitySystem, Dallas, TX. cence in conjunction with routine histopathology.DIF f Baylor Collegeof Dentistry. may reveal nuclear deposits f Privatepractice, Dallas, TX; Baylor Collegeof Dentistry. of immunoglobulin G $ HarrisMethodist Southwest Hospital, Fort Worth, TX. (lgG) in a speckledpattern mainly in the basal one-

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