Periodontology 2000, Vol. 12, 1996, 33-39 Printed in Denmark . All rights reserved

Copyright 0 Munksgaard 1996

PERIODONTOLOGY 2000 ISSN 0906-6713

Manual periodontal probing in supportive periodontal treatment GARY C. ARMITAGE

Although straight steel probes were in widespread use by dentists in the early 19OOs, they were primar- ily used for identifymg the origin and extent of peri- odontal abscesses (12). In the 1920s, Simonton (63) and Box (13) first advocated the use of calibrated periodontal probes to assess the extent of damage to periodontal structures caused by periodontitis. Over the next 50 years, measurement of probing depths gradually came to be recognized as an essential component of a complete oral examination. Prior to 1970, standard periodontal textbooks placed differ- ent degrees of emphasis on the importance of rou- tinely recording probing depths. Most regarded it as an essential component of a complete periodontal examination (10, 19, 50, 57, 66, 771, whereas some suggested that the detailed recording of probing depths was only necessary prior to surgical pro- cedures (47). Others, however, took a more neutral position and commented that probing depths could be measured with a calibrated probe if it was deemed necessary under the circumstances (24, 25). Virtually all authors recognized that probing depths were not necessarily an accurate assessment of the actual amount of periodontal damage. This view is quite valid, since the position of the gingival margin, the reference point from which probing depths are made, is subject to extensive variability. As will be seen, the modern view of the diagnostic and clinical value of probing depth is not radically different from that suggested by earlier authors.

Types of measurements recorded by periodontal probes

Calibrated periodontal probes can be used to make 3 different types of measurements: 1) probing depth, 2) clinical attachment level and 3) relative attach- ment level (56).

Probing depth

Probing depth is the distance from the gingival mar- gin to the base of the probeable crevice. It is a clin- ical approximation of the depth of a periodontal pocket (5). The primary clinical importance of peri- odontal pockets is that they are potential habitats for a pathogenic microbiota. The deeper the pocket, the more difficult it is for both the therapist and patient to clean (14, 60, 78). This does not mean, however, that all sites with deepened probing depths harbor a pathogenic microbiota. Nor does it mean that all sites with deepened probing depths need to be sur- gically reduced. However, data from multiple longi- tudinal studies indicate that sites with probing depths of 2-6 mm are at a significantly higher risk of developing additional attachment loss if left un- treated (8, 17, 29, 34, 76). The recording of probing depths prior to treatment is important because it gives the clinician a reasonable idea on a site-by-site basis of where the potential problem areas are located. Probing depths need to be evaluated in the context of other clinical findings. For example, a site with a probing depth of 5 mm with no sign of peri- odontal infection should be viewed quite differently than a site of similar depth with bleeding on probing and suppuration. The latter pocket is, of course, of more concern than the former, since multiple longi- tudinal studies indicate that bleeding on probing and suppuration increase the risk for additional attachment loss if left untreated (4, 8, 16, 17, 29, 34, 44, 45, 49, 55, 76).

As mentioned above, the primary problem with probing depth as a clinical measurement is that it does not necessarily reflect the actual amount of attachment loss or damage to periodontal structures. Fluctuations in the position of the gingival margin may occur during gingival inflammation (swelling) or in cases of recession. Therefore, changes in position in both coronal and apical directions make the gingival

33

Armitage

margin an unreliable landmark from which to make clinical measurements from one visit to the next. This problem was recognized by clinicians in the past and was the major reason that some of them did not strongly advocate the routine recording of probing depths. For example, Glickman (24) suggested that merely characterizing the probing depths as “slight”, “moderate” or “severe” was sufficient for treatment planning purposes. In his opinion, “Determination of the exact depth in millimeters constitutes little ad- ditional information which is of clinical use”. The main difficulty with this approach is that the criteria for slight, moderate or severe probing depths were not stated. If treatment decisions are to be based at least partly 011 probing depths, then it is much better to be consistent and determine the probing depths in milli- meters. Nevertheless, Glickman and most of his con- temporaries regarded assessment of loss of attach- ment as the more reliable measurement of peri- odontal damage. This view is in complete accord with current thought on the subject.

Clinical attachment level

Clinical attachment level is the distance from the cementoenamel junction to the base of the probe- able crevice. It is a clinical approximation of the loss of connective tissue attachment from the root sur- face (5). This measurement is extremely useful in clinically monitoring attachment level changes on a site-by-site basis from one visit to the next. Indeed, in current clinical practice, clinical attachment level measurements are the most practical method of as- sessing treatment outcomes. They are the primary basis upon which a clinician can be reasonably cer- tain that a program of supportive periodontal treat- ment is, or is not, working. The primary difficulty with clinical attachment level measurements is that they require more skill to obtain than probing depths, since detection of the cementoenamel junc- tion is necessary. At sites where the gingival margin is apical to the cementoenamel junction, the meas- urement is rather easy to record. When the gingival margin is coronal to the cementoenamel junction, the clinician must detect the cementoenamel junc- tion through tactile exploration with the probe tip. This can be difficult, but with practice, the skill can be mastered.

Relative attachment level

Relative attachment level is the distance from a fixed landmark, other than the cementoenamel junction,

to the base of the probeable crevice. When the cementoenamel junction is not detectable or is missing due to a dental restoration, the clinical attachment level cannot be measured. In such situ- ations, another fixed landmark such as the margin of a dental restoration or incisal edge of the tooth can be used as a reference point from which a meas- urement can be made. Relative attachment level measurements serve the same purpose as clinical attachment level measurements, providing a good estimate of treatment outcomes. Measurements of relative attachment level are not a new idea, having been suggested over 50 years ago by Miller, who de- signed a special probe for this purpose (50).

How accurate are measurements taken with periodontal probes?

Although measurements taken with periodontal probes are clinically useful approximations of dam- age to periodontal structures, periodontal probing has several sources of error that makes it a some- what imprecise method of measurement. However, as will be seen, the measurements are not so impre- cise as to negate their clinical usefulness.

Probe penetration and connective tissue attachment

In the past two decades, numerous studies (2, 3, 15,

have attempted to establish how accurately meas- urements of the clinical attachment loss represent the true position of the connective tissue attach- ment. Most of these studies either 1) compared pre- extraction measurements of probing depth or clin- ical attachment loss with post-extraction estimates of probe penetration relative to the connective tissue attachment level (20, 46, 48, 61, 62, 64, 70, 71), or 2) histologically assessed the extent of probe penetra- tion (2, 3, 20-22, 36, 38, 53, 67, 72, 73). As summar- ized in Table 1, most studies agree that, at sites with moderate to severe inflammation, as might be found in cases of periodontitis, probes penetrated an aver- age of less than 0.5 mm past the apical termination of the junctional epithelium when gentle insertion forces (approximately 0.2 to 0.5 N) were used. Most studies also clearly show that probe penetration in- creases with higher insertion forces (22, 52, 61, 70, 73) and at inflamed sites (3, 11, 15, 20, 36, 38, 52, 61, 68, 69, 74). At noninflamed sites, such as successfully treated ones, probes tend to stop coronal to the api-

20-22, 36, 38, 42, 46, 48, 53, 59, 61, 62, 64, 70-74)

34

Manual periodontal probing in supportive periodontal treatment

Table 1. Periodontal probe penetration in relation to connective tissue attachment levels at healthy and diseased sites

Average distance from probe tip to apical termination of the junctional epithelium (mm z SD)

Inflamed or untreated -

Reference Type of study Insertion force" Healthy or treated periodontitis Armitage et al. (3) Histology, dog (25 ponds") -0.39?0.08 f0.24t0.06

____._.__

(n=40) (n=40) Spray et al. (67) Histology, humans (15-20 g) ND +0.27t0.15

van der Velden Histology, dogs (0.5 N) -0.20b +0.23 & Jansen (73) (n=4) (n=4)

Jansen et al. (38) Histology, dogs (Nonstandardized) ND +0.50 ( n = l l )

Hancock Histology, monkeys (Nonstandardized) -2.84-tO.87 +0.24 t 0.06 & Wirthlin (36) (n= 10) (n=7)

~

Fowler et al. (20) Histology, humans (0.5 N) - 0.73 20.80b +0.45t0.34

Aguero et al. (2) Histology, humans (0.3 N) - 0.40 -C 0.70 +0.17t1.70 __.

(n=12) (n= 15)

(n=lO) (n=8)

~-

Sivertson Extracted teeth, humans (Nonstandardized) ND & Burgett (64)

+0.08 (n= 116)

Listgarten et al. (46) Extracted teeth, humans (Nonstandardized) ND +0.30

Robinson Extracted teeth, humans (25 ponds) - 0.54 20.29 +0.27+0.39

van der Velden (70) Extracted teeth, humans (0.5 N) ND -0.34t0.97

Magnusson Extracted teeth, humans (Nonstandardized) -0.31 -t0.4gb +0.2920.50

van der Velden (74) Extracted teeth, humans (0.75 N) -0.09?0.39 +0.2720.92

(n=38)

& Vitek (61) ( n 2 6 ) ( n 2 6 )

( n 54)

( n = l l ) (n= 18

(n=32) (n=26)

._ __ -~ & Listgarten (48) - - _ _ ~

Polson et al. (59) Gingival biopsy, humans (25 g) -0.2520.04 ND (n=22)

"1 gram=l pond=0.0098 newton (N). bData from treated sites. 'Insertion force for the periodontitis sites not standardized. dA negative sign indicates probe penetration was coronal to the apical termination of the junctional epithelium. A positive sign indicates probe penetration apical to the apical termination of the junctional epithelium. ND=not determined.

cal termination of the junctional epithelium (20, 21, 48, 73). Although at individual sites the discrepancy between clinical attachment loss measurements and the actual position of the connective tissue attach- ment may be several millimeters, most of the time the probe tip penetrates to within 1 mm of the apical termination of the junctional epithelium.

The clinically important conclusions that can be drawn from these studies are that 1) probes do not precisely measure the true level of the connective tissue attachment, 2) gains in clinical attachment level after treatment do not necessarily mean that new connective tissue attachment has been achieved, and 3) most of the time, clinical attach- ment level measurements are within 1 mm of the connective tissue attachment level and are therefore clinically useful approximations of attachment loss.

Reproducibility of probing measurements

The variables that affect the reproducibility of meas- urements taken with periodontal probes are well known: insertion force (18, 22, 52, 701, probe place- ment and angulation (51, 81, 821, inflammatory sta- tus of the tissues (3, 15, 20, 22, 40, 61), diameter of the probe tip (6, 42) and probe-to-probe variations in calibration markings (75, 83). Most of these vari- ables can be controlled somewhat in day-to-day clinical practice situations. If one accepts that some variation will occur, it is fair to ask whether the pro- cess of taking measurements with manual peri- odontal probes is so flawed that the results are not clinically meaningful. As will be seen below, meas- urements carefully taken with periodontal probes are reasonably reproducible and are meaningful.

35

Arrnitane

In epidemiological and clinical studies measure- ments taken with periodontal probes are frequently the maior outcome variable. As a result, many studies have been conducted to determine whether measurements of probing depth and clinical attach- ment loss are reproducible when taken at two differ- ent times by experienced clinicians (7, 23, 37, 39, 40, 43, 54, 58, 65, 79, 80). In these studies, perfect agree- ment (j10.0 mm) for probing depth measurements ranged from 33 to 70%; for clinical attachment level measurements the range was 32 to 71.7%; and for relative attachment level measurements it was 39.8 to 55.4% (Table 2). When the agreement threshold was set at 21.0 mm, the percentage of agreement between the first and second examinations dramati- cally improved with the ranges being: Probing depth=81.2 to 99.6%, Clinical attachment loss=84 to 98.8%, Relative attachment loss=90 to 94.1% (Table 2). If the agreement threshold was set at 22.0 mm, the reproducibility of all measurements approached 100%. These findings should be reassuring to prac- ticing clinicians, since they demonstrate that care- fully taken measurements with periodontal probes are reasonably reproducible from one examination to the next.

In clinical research studies dealing with the etiol- ogy of periodontitis, it is important that scientifically

rigorous criteria for progression be used. For ex- ample, if one is going to be absolutely certain that a specific microorganism is associated with the pro- gression of periodontitis, then the criteria used for progression must be rigidly established. In such studies, changes in clinical attachment loss meas- urements are currently the best way to determine progression. Since the standard deviation of clinical attachment loss measurements is approximately 1 mm, it has become common practice in most re- search studies to set the threshold for progression at 2 to 3 mm times the standard deviation of the measurement system (1, 9, 26-35, 41, 44, 45). This means that for a scientist to be certain that pro- gression has occurred, a 2- to 3-mm change in clin- ical attachment loss must be demonstrated. From a scientific point of view, this is a completely valid ap- proach. Indeed, it is necessary if any scientifically valid conclusions are to be drawn.

Interpretation of probing measurements for patients on supportive periodontal treatment

Compared with clinical research situations, a very different set of circumstances exists in day-to-day

Table 2. Intraexaminer reproducibility of probing measurements: probing depth, clinical attachment level and relative attachment level

~

Percentage agreement between first and second examinationsa 20.0 mm ? L O mm ?2.0 mm

Clinical Relative Clinical Relative Clinical Relative No. of Probing attach- attach- Probing attach- attach- Probing attach- attach-

Reference sites depth ment level ment level depth ment level ment level depth ment level ment level Glavirid 1335 - - - 99.6 94.8 - - - -

& Loe (23) - - - Smith 453 - 81.2 94.5 - - -

~- ~- ~- et al. (65)

et al. (37)

ct a l (7)

et al. (39)

Isidor 312 60.9 - 55.4 95.6 - 93.9 99.8 - 99.6

_______ Badersten 852 38 32 42 88 84 90 97 97 97

Janssen 1069 67.4 - 96.4 - 99.2 - - ~- --__

- -

- - Osborn 156 70 56 99 93 100 100 -

~ - - et al. (58)

et al. (43)

- - _ _ Kingman 1867 - 71.7 - - 98.8 - - - -

~ - Mullally & 656 69.4 98.5 - - - - - Linden (54)

Wang 221 33.0 - 39.8 96.4 - 94.1 99.2 - 99.5

- - et al. (79)

-- ~

'In these ctudier the time interval between the first dnd second examinations ranged from 30 minutes to 3 weeks

Manual periodontal probing in supportive periodontal treatment

clinical practice. It is not reasonable, or in the best interest of patients, to wait until 3 mm of additional attachment loss has occurred before clinical inter- vention is initiated. Clinicians must make treatment decisions before this much additional damage has developed. The exact set of clinical conditions that must be in place before additional treatment is rendered has not been established. Therefore, clin- icians must be guided by the entire clinical picture; simple reliance on one clinical parameter will not suffice. For example, if a patient on a supportive periodontal treatment program experiences a 1-mm increase in clinical attachment loss without any clin- ical signs of infection, it should alert the clinician that a possible problem exists. No special thera- peutic intervention may be required, but the site should be carefully evaluated at the subsequent visit. On the other hand, a 1-mm increase in clinical attachment loss at a site with heavy deposits of plaque and signs of infection most certainly would prompt the clinician to therapeutically intervene. This should be the approach even though a 1-mm change in clinical attachment loss may not be “real” since it is within the measurement error of manual probes. Since a 2-mm increase in clinical attach- ment loss is within the reliable measurement range of probing, such a change has a high probability of being “real.” In such situations a more aggressive therapeutic approach may be indicated, such as shortening the interval at which the patient is being seen for supportive periodontal treatment. However, the exact treatment rendered will depend on the en- tire set of clinical findings. No single clinical finding should be used as a stand-alone determinant for making treatment decisions.

Finally, it should be emphasized that in a support- ive periodontal treatment program, clinical attach- ment levels are the best measurements to monitor the stability of the periodontal tissues. However, if clinical attachment level measurements have not been taken, probing depths are a reasonable “sec- ond-best”. The advantage of probing depths is that they are easy to obtain; the disadvantage is that they are not as good an indicator of periodontal stability as clinical attachment level measurements.

References

1. Aeppli DM, Boen JR, Bandt CL. Measuring and interpreting increases in probing depth and attachment loss. J Peri- odontol 1985: 56: 262-264.

2. Aguero A, Garnick JJ, Keagle J, Steflik DE, Thompson WO.

Histological location of a standardized periodontal probe in man. J Periodontol 1995: 66: 184-190.

3. Armitage GC, Svanberg GK, Loe H. Microscopic evaluation of clinical measurements of connective tissue attachment levels. J Clin Periodontol 1977: 4: 173-190.

4. Armitage GC, Jeffcoat MK, Chadwick DE, Taggart EJ Jr, Nu- mabe Y, Landis JR, Weaver SL, Sharp TJ. Longitudinal evaluation of elastase as a marker for the progression of periodontitis. J Periodontol 1994: 65: 120-128.

5. Armitage GC. Clinical evaluation of periodontal diseases. Periodonto12000 1995: 7 : 39-53.

6. Atassi Newman HN, Bulman JS. Probe tine diameter and probing depth. J Clin Periodontol 1992: 19: 301-304.

7. Badersten A, Nilveus R, Egelberg J. Reproducibility of prob- ing attachment level measurements. J Clin Periodontol

8. Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical periodontal therapy. VII. Bleeding, suppuration and prob- ing depth in sites with probing attachment loss. J Clin Peri- odontol 1985: 12: 432-440.

9. Best AM, Burmeister JA, Gunsolley JC, Brooks CN, Schenk- ein HA. Reliability of attachment loss measurements in a longitudinal clinical trial. J Clin Periodontol 1990: 17: 564- 569.

10. Beube FE. Periodontology. New York Macmillan, 1953:

11. Birek r: McCulloch CAG, Overall CM. Measurements of probing velocity with an automated periodontal probe and the relationship with experimental periodontitis in the cynomolgus monkey (Macucu fascicularis). Arch Oral Biol 1989: 34: 793-801.

12. Black GV Special dental pathology. 1st edn. Chicago: Med- ico-Dental Publishing Co., 1915: 371.

13. Box HK. Treatment of the periodontal pocket. Toronto: University of Toronto Press, 1928: 83.

14. Buchanan SA, Robertson PB. Calculus removal by scaling/ root planing with and without surgical access. J Periodontol

15. Caton J, Greenstein G, Polson AM. Depth of periodontal probe penetration related to clinical and histologic signs of gingival inflammation. J Periodontol 1981: 52: 626-629.

16. Chaves ES, Caffesse RG, Morrison EC, Stults DL. Diagnostic discrimination of bleeding on probing during maintenance periodontal therapy. Am J Dent 1990: 3: 167-170.

17. Claffey N, Nylund K, Kiger R, Garrett S, Egelberg J. Diagnos- tic predictability of scores of plaque, bleeding, suppuration and probing depth for probing attachment loss. 3 1/2 years of observation following initial periodontal therapy. J Clin Periodontol 1990: 17: 108-114.

18. Durwin A, Chamberlain H, Renvert S, Garrett S, Nilveus R, Egelberg J. Significance of probing force for evaluation of healing following periodontal therapy. J Clin Periodontol

19. Fish EW. Periodontal disease. A manual of treatment and atlas of pathology. London: Eyre and Spottiswoode Pub- lishers, 1946: 59.

20. Fowler C, Garrett S, Crigger M, Egelberg J. Histologic probe position in treated and untreated human periodontal tissues. J Clin Periodontol 1982: 9: 373-385.

21. Garnick JJ, Spray JR, Vernino DM, Klawitter JJ. Demon- stration of probes in human periodontal pockets. J Peri- odontol 1980: 51: 563-570.

22. Garnick JJ, Keagle JG, Searle JR, King GE, Thompson WO.

1984: 11: 475-485.

376-378.

1987: 58: 159-163.

1985: 12: 306-311.

37

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

Gingival resistance to probing forces. 11. The effect of in- flainriiation and pressure on probe displacement in beagle dog gingivitis. J Periodontol 1989: 60: 498-505. Glavind L, Loe H. Errors in the clinical assessments of peri- odontal destruction. J Periodont Res 1967: 2: 180-184. Glickman I. Clinical periodontology. 1st edn. Philadelphia: W.B. Saunders Co., 1953: 550. Goldrnan HM. Periodontia. 2nd edn. St. Louis: C.V. Mosby Co., 1949: 282. Goodson JM, Tanner ACR, Haffajee AD, Sornberger GC, Socransky SS. Patterns of progression and regression of ad- vanced destruction periodontal disease. J Clin Periodontol

Goodson JM. Clinical measurements of periodontitis. J Clin Periodontol 1986: 13: 446-455. Goodson JM. Diagnosis of periodontitis by physical meas- urement: interpretation from episodic disease hypothesis. I Periodontol 1992: 63: 373-382. Grbic IT, Lamster IB. Risk indicators for future clinical attachment loss in adult periodontitis. Tooth and site vari- ables J Periodontol 1992: 63: 262-269. Gunsolley JC, Best AM. Change in attachment level. J Peri- odontol 1988: 59: 450-456. Haffajee AD, Socransky SS, Goodson JM. Clinical par- ameters as predictors of destructive periodontal disease ac- tivity. J Clin Periodontol 1983: 10: 257-265. Haffajee AD, Socransky SS, Goodson JM. Comparison of different data analyses for detecting changes in attachment level. J Clin Periodontol 1983: 10: 298-310. Haffajee AD, Socransky SS, Lindhe J, Kent RL, Okamoto H, Yoneyama T. Clinical risk indicators for periodontal attach- ment loss. J Clin Periodontol 1991: 18: 117-125. Haffajee AD, Socransky SS, Smith C, Dibart S. Microbial risk indicators for periodontal attachment loss. J Periodont Res 1991: 26: 293-296. Haffajee AD, Socransky SS, Smith C, Dibart S. Relation of baseline microbial parameters to future periodontal attachment loss. J Clin Periodontol 1991: 18: 744-750. Hancock EB, Wirthlin MR. The location of the periodontal probe tip in health and disease. J Periodontoll981: 52: 124- 129. Isidol- F, Karring T, Attstrom R. Reproducibility of pocket depth and attachment level measurements when using a flexible splint. J Clin Periodontol 1984: 11: 662-668. Jansen J, Pilot T, Corba N. Histologic evaluation of probe penetration during clinical assessment of periodontal attachment levels. An investigation of experimentally in- duced periodontal lesions in beagle dogs. J Clin Peri- odontol 1981: 8: 98-106. Janssen PTM, Faber JAJ, van Palenstein Helderman WH. Non-Gaussian distribution of differences between dupli- cate probing depth measurements. J Clin Periodontol 1987:

Janssen PTM, Faber JAJ, van Palenstein Helderman WH. Ef- fect of probing depth and bleeding tendency on the repro- ducibility of probing depth measurements. J Clin Peri- odontol 1988: 15: 565-568. Kaldahl WB, Kalkwarf KL, Patil KD, Molvar Ml? Relationship of gingival bleeding, gingival suppuration, and supragin- gival plaque to attachment loss. J Periodontol 1990: 61: 347-351. Keagle JG, Garnick JJ, Searle JR, King GE, Morse PK. Gingi- val resistance to probing forces. I. Determination of opti- mal probe diameter. J Periodontol 1989: 60: 167-171.

1982: 9: 472-481.

14: 345-349.

43. Kingman A, Loe H, h e r u d A, Boysen H. Errors in measur- ing parameters associated with periodontal health and dis- ease. J Periodontol 1991: 62: 477-486.

44. Lang NP, Joss A, Orsanic T, Gusberti FA, Siegrist BE. Bleed- ing on probing. A predictor for the progression of peri- odontal disease? J Clin Periodontol 1986: 13: 590-596.

45. Lang NP, Adler R, Joss A, Nyman S. Absence of bleeding on probing. An indicator of periodontal stability. J Clin Peri- odontol 1990: 17: 714-721.

46. Listgarten MA, Mao R, Robinson PJ. Periodontal probing and the relationship of the probe tip to periodontal tissues. J Periodontol 1976: 47: 511-513.

47. Macphee T, Cowley G. Essentials of periodontology and periodontics. Oxford: Blackwell Scientific Publications,

48. Magnusson I, Listgarten MA. Histological evaluation of probing depth following periodontal treatment. J Clin Peri- odontol 1980: 7: 26-31.

49. Magnusson I , Marks RG, Clark WB, Walker CB, Low SB, McArthur WP Clinical, microbiological and immunological characteristics of subjects with “refractory” periodontal disease. J Clin Periodontol 1991: 18: 291-299.

50. Miller SC. Textbook of periodontia. 2nd edn. Philadelphia: Blakiston Co., 1943: 222-225.

51. Mintzer RE, Derdivanis Jl? Automated periodontal probing and recording. Curr Opin Periodontol 1993: 60-66.

52. Mombelli A, Muhle T, Frigg R. Depth-force patterns of peri- odontal probing. Attachment-gain in relation to probing

1969: 112-113.

53.

54.

55.

56.

57.

58.

59.

60.

61.

62.

63.

force. J Clin Periodontol 1992: 19: 295-300. Moriarty JD, Hutchens LH, Scheitler LE. Histological evalu- ation of periodontal probe penetration in untreated facial molar furcations. J Clin Periodontol 1989: 16: 21-26. Mullally BH, Linden GJ. Comparative reproducibility of proximal probing depth using electronic pressure-con- trolled and hand probing. J Clin Periodontol 1994: 21: 284- 288. Muller H-P, Heinecke A, Lange DE. Postoperative bleeding tendency as a risk factor in Actinobacillus actinornycetern- comitans-associated periodontitis. J Periodont Res 1993: 28: 437443. Nevins M, Becker W, Kornman K, ed. Proceedings of the World Workshop in Clinical Periodontics. Chicago: Amer- ican Academy of Periodontology, 1989: 1-23. Orban B. Periodontics. A concept - theory and practice. 1st edn. St. Louis: Mosby, 1958: 188-190, 512-513. Osborn J, Stoltenberg J, Huso B, Aeppli D, Pihlstrom B. Comparison of measurement variability using a standard and constant force periodontal probe. J Periodontol 1990:

Polson AM, Caton JG, Yeaple RN, Zander HA. Histological determination of probe tip penetration into gingival sulcus of humans using an electronic pressure-sensitive probe. J Clin Periodontol 1980: 7: 479-488. Rabbani GM, Ash MM, Caffesse RG. The effectiveness of subgingival scaling and root planing in calculus removal. J Periodontol 1981: 52: 119-123. Robinson PJ, Vitek RM. The relationship between gingival inflammation and resistance to probe penetration. J Peri- odont Res 1979: 14: 239-243. Saglie R, Johansen JR, Flntra L. The zone of completely and partially destroyed periodontal fibers in pathological pockets. J Clin Periodontol 1975: 2: 198-202. Simonton FV Examination of the mouth - with special ref- erence to pyorrhea. J Am Dent Assoc 1925: 12: 287-295.

61: 497-503.

Manual periodontal probing in supportive periodontal treatment

64. Sivertson JE Burgett FG. Probing of pockets related to attachment level, J Periodontol 1976: 47: 281-286.

65. Smith LW, Suomi JD, Greene JC, Barbano JP A study of in- tra-examiner variation in scoring oral hygiene status, gingi- val inflammation and epithelial attachment level. J Peri- odontol 1970: 41: 671-674.

66. Sorrin S. The practice of periodontia. New York McGraw- Hill, 1960: 125.

67. Spray JR, Garnick JJ, Doles LR, Klawitter JJ. Microscopic demonstration of the position of periodontal probes. J Peri- odontol 1978: 49: 148-152.

68. Tessier J-F, Ellen Rf: Birek P, Kulkarni GV, McCulloch CAG. Relationship between periodontal probing velocity and gingival inflammation in human subjects. J Clin Peri- odontol 1993: 20: 41-48.

69. Tessier 1-F, Kulkarni GV, Ellen RP, McCulloch CAG. Probing velocity: novel approach for assessment of inflamed peri- odontal attachment. 1 Periodontol 1994: 65: 103-108.

70. van der Velden U. Probing force and the relationship of the probe tip to the periodontal tissues. J Clin Periodontol 1979: 6: 106-114.

71. van der Velden U. Influence of periodontal health on prob- ing depth and bleeding tendency. J Clin Periodontol 1980:

72. van der Velden U, Jansen J. Probing force in relation to probe penetration into the periodontal tissues in dogs, A microscopic evaluation. J Clin Periodontol 1980: 7: 325- 327.

73. van der Velden U, Jansen J. Microscopic evaluation of pocket depth measurements performed with six different probing forces in dogs. J Clin Periodontol 1981: 8: 107-116.

74. van der Velden U. Location of probe tip in bleeding and

7: 129-139.

non-bleeding pockets with minimal gingival inflammation. J Clin Periodontol 1982: 9: 421-427.

75. van der Zee E, Davies EH, Newman HN. Marking width, calibration from tip and tine diameter of periodontal probes. J Clin Periodontol 1991: 18: 516-520.

76. Vanooteghem R, Hutchens LH, Garrett S, Kiger R, Egelberg J. Bleeding on probing and probing depth as indicators of the response to plaque control and root debridement. J Clin Periodontol 1987: 14: 226-230.

77. Wade AB. Basic periodontology. Bristol: John Wright & Sons, 1960: 183-184.

78. Waerhaug J. Healing of the dento-epithelial junction fol- lowing subgingival plaque control. 11. As observed on ex- tracted teeth. J Periodontol 1978: 49: 119-134.

79. Wang S-F, Leknes KN, Zimmerman GI, Sigurdsson TJ, Wikesjo UME, Selvig KA. Reproducibility of periodontal probing using a conventional manual and an automated force-controlled electronic probe. J Periodontol 1995: 66:

80. Wang S-F, Leknes KN, Zimmerman GJ, Sigurdsson TJ, Wikesjo UME, Selvig KA. Intra- and inter-examiner repro- ducibility in constant force probing. J Clin Periodontol 1995: 22: 918-922.

81. Watts T. Constant force probing with and without a stent in untreated periodontal disease: the clinical reproducibility problem and possible sources of error. J Clin Periodontol 1987: 14: 407-411.

82. Watts TLP Probing site configuration in patients with un- treated periodontitis. A study of horizontal positional error. 1 Clin Periodontol 1989: 16: 529-533.

83. Winter AA. Measurement of the millimeter markings of periodontal probes. J Periodontol 1979: 50: 483485.

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