Periodontitis has now been established as a major chronic inflammatory disease. There exist significant links to systemic health conditions under the umbrella of the “oral systemic link”. Recent epidemiologic research has linked periodontal pathogens to several systemic diseases, including cardiovascular disease, diabetes mellitus, and preterm birth, possibly mediated through markers of systemic infection and inflammation. Associations with osteoporosis, respiratory disease, and systemic infections have also been observed. Many of these follow the same inflammatory cascade including the overproduction of host inflammatory mediators as cytokines.1 The incidence of unmanaged periodontitis results in primary tooth loss in a population, especially as age increases.
The Rationale for a Periodontal Examination
The incidence of periodontitis in the United States has always been considered common, but reached landmark levels with the Centers for Disease Control and Prevention (CDC) report of 2009/2010. This survey suggested that when considering all Americans over the age of thirty, 47.2 % of the population demonstrated a diagnosis of periodontitis. The breakdown was distributed as 8.7%, 30.0%, and 8.5% with mild, moderate, and severe periodontitis, respectively. For adults aged 65 years and older, 64% had either moderate or severe periodontitis. This survey has provided direct evidence for a high burden of periodontitis in the adult U.S. population.2 The primary data input was based on periodontal probing for pocket depth and attachment loss.
A thorough comprehensive oral health examination includes a periodontal assessment. The parameters for the periodontal examination include periodontal probing (charting,) oral health and medical health history, radiographs, and additional components, that lead to a diagnosis and treatment plan. The American Academy of Periodontology suggests the following procedures should be included in a comprehensive periodontal evaluation:3
Examination of teeth and dental implants to evaluate the topography of the gingiva and related structures; to measure probing depths, the width of keratinized tissue, gingival recession, and attachment level; to evaluate the health of the subgingival area with measures such as bleeding on probing and suppuration; to assess clinical furcation status; and to detect endodontic–periodontal lesions.
While a periodontal charting may be considered a mainstay as for a periodontal examination, the components of such a charting can include the
- Pocket depth
- Attachment level designation
- Furcation involvement
- Bleeding on probing
Challenges in performing a periodontal examination
There is minimal evidence regarding the frequency that a dental office performs periodontal probing on their patients. However, collecting periodontal data to establish a diagnosis, treatment plan and implement care, is considered the “standard of care” with many regulatory bodies. A survey of dental practitioners in Nova Scotia asked if they routinely evaluated the periodontal status of their patients.4 The clear majority (94.8%) performed a “periodontal examination” but only 37.8% reported actually doing a full mouth charting with probing depths. Performance of the Periodontal Screening and Recording (PSR) metric was 32.5%. Because of time and financial constraints, a complete periodontal evaluation for every patient that walks into a general dental practice, at every appointment, may not be feasible. To circumvent these constraints, various screening tests for periodontal disease in the general dental practice have been proposed and implemented. The Periodontal Screening and Recording index (PSR) has been recommended by the American Dental Association and the American Academy of Periodontology. The low prevalence of probing depth measurements by general practitioners was reported by other investigators. A study in the United Kingdom revealed that only 13% of dentists completed a periodontal charting, but a majority performed a visual examination of periodontal tissues.5
A study by McFall utilizing patient records of general dental practitioners in North Carolina, found only 20.5% listed the presence of periodontal probing, and periodontal diagnosis had a frequency of 16.3%.6 The data suggests that while radiographs may be used, other diagnostic information for a periodontal assessment was minimal. The majority of patient records do not contain sufficient diagnostic information to describe the patients’ periodontal health.
Validity versus Reliability in Periodontal Probing
Calibration of clinicians performing periodontal charting can vary as to both validity and reliability. Both qualities are essential for consistency in performing an accurate examination to assist in a diagnosis.
Errors in validity can be created by errors in proper angulation of the probe. (Fig. 1) Another error in validity can occur with the use of a probe with a diameter greater than 0.5 millimeters. The resulting depths will be shallow compared to accurate probing.
Errors in validity can be created by errors in proper angulation of the probe.Errors in reliability occur where different clinicians continue to have different probing depths with the same site and the same patient. This can be due to several factors:
- Each clinician uses different angulations of the probe
- While most consider that the correct probing force should be 15 grams, different practitioners can have different tactile responses. This is especially true with inflamed versus fibrotic gingiva
- Clinicians utilizing probes with different markings and different diameters will ultimately have different recordings as compared to their colleagues
Over the years, several types of probes have been created, in an attempt to overcome validity and reliability limitations. Hefti created the following category system of periodontal instrumentation:7
Manual probes: (Fig. 2) Generally, most periodontal probes are made of metal or plastic (titanium for dental endosseous implants) and in materials that can be sterilized for infection control. They can have different angulations, markings and diameters of the handle. The clinician reads the markings and records on paper, keyboard, foot switch, or voice actuation.
Pressure sensitive probes: (Fig. 3) These probes have similar qualities to manual probes but contain pressure sensitive devices such as springs, that create a constant force for probing. This decreases variability and increases reliability among practitioners.
Pressure sensitive probes with electronic data gathering: (Fig. 4) These probes are designed to work with constant force and have electronic transducers that can read differences of 0.1 millimeters in probing depth, when placed in the gingival sulcus.8 These probes can also document these readings in pre-established software programs.
The results of most studies evaluating both validity and reliability of periodontal probing suggest that the most common variables are: degree of inflammation, probing force, probing angulation, probe design and depth of the pocket. There is a direct relationship of increased error with increased pocket depth.9 After several decades, most clinicians still rely on a manual metal periodontal probe.
Periodontal charting (Fig. 5) can be a very time-consuming process in a busy dental practice. Some estimates suggest 10 to 14 minutes for a complete charting including pocket depths, furcation identification and bleeding points. In most practices, periodontal details are collected by a dental hygienist (often without assistance), who enters the data either manually with “pencil and paper” or on a keyboard.
This may provide a major reason why periodontal charting is so infrequent.
To increase the accuracy of periodontal probing in the practice:
- All periodontal probes utilized should be of the same type, including diameter and markings (Use same manufacturer)
- All clinicians within the practice should undergo appropriate training as to probe placement, including angulation and correct periodontal probe pressure.
- All team members who perform periodontal probing must be calibrated to each other for consistent readings with multiple operators
To increase the frequency of periodontal charting, the following should be considered:
1) Charting should be a solo activity with one practitioner collecting and entering data into a corresponding software system. In addition, it is highly ineffective and not ergonomically sound to perform charting, and then leave the oral cavity to record the data. Quality voice actuation with accuracy is essential for efficient periodontal charting. This actuation should be unique and understand the voice of each individual clinician.
For convenience, the entire exam should be voice actuated and free from the traditional foot controller. This also enhances infection control. Solo data collection benefits the practice bottom line since a dental assistant is not required during the examination process.
2) The resulting chart should be graphic, not only to assist the clinician in diagnosis, but also for patient “co-discovery “, as an instrument to explain their periodontal condition by illustrating which specific areas have disease and require attention.
The chart should be electronic so that it can be utilized by third parties for reimbursement. When possible, software systems should contain platforms to allow data to be synthesized into artificial intelligence schematics to show risk assessment.
Periodontal disease is a major chronic inflammatory disease that results in tooth loss and has a direct impact on the systemic health of dental patients.10 The detection of periodontal disease requires a periodontal examination which includes accurate periodontal probing. This will ensure proper diagnosis, evaluation of prognosis and appropriate periodontal management. Potential improvements in the procedure of periodontal charting, will increase accuracy and encourage frequency of this “standard of care” and optimize patient oral health.
Oral Health welcomes this original article.
1 Periodontal health and systemic disorders. Teng YT, Taylor GW, Scannapieco F, et al. J Can Dent Assoc. 2002;68:188–192.
2 Prevalence of periodontitis in adults in the United States: 2009 and 2010 P I Eke 1 , B A Dye, L Wei, G O Thornton-Evans, R J Genco, CDC 2012 Oct;91(10):914-20. Journal of Dental Research.
3 Comprehensive Periodontal Therapy: A Statement by the American Academy of Periodontology July 2011, American Academy of Periodontology.
4 The Periodontal Examination Profile of General Dentists in Nova Scotia, Canada Edmond Ghiabi, Swarna Weerasinghe. January 2011 Journal of Periodontology.
5 Variation in periodontal referral in 2 regions in the UK G J Linden, 1 M Stevenson, F J Burke, J Clin Periodontol 1999 Sep;26(9):590-5.
6 Presence of Periodontal Data in Patient Records of General Practitioners† Walter T. McFall Jr., James D. Bader, R. Gary Rozier, Dianne Ramsey, July 1988 Journal of Periotology.
7 Periodontal Probing. Hefti AF. Crit Rev Oral Biol Med 1997;8:336-56.
8 Reproducibility of probing depth measurement using a constant-force electronic probe: analysis of inter- and intraexaminer variability. Araujo MW, Hovey KM, , Benedek JR, et al. J Periodontol. 2003;74:1736-1740.
9 Periodontal Probing: A Review Kwthar Nassar Al Shayeb, Dr Sulaiman Primary Dental Journal.August 2014.
10 Disease progression in periodontally treated and untreated patients – a retrospective study Thomas Kocher, Jörgen König, Uwe Dzierzon Hassem Sawaf, Hans-Christian Plagmann. December 2001 Journal Clinical Periodontology.