How To Calculate Clinical Attachment Loss
| Department IV | PERIODONTAL MEASUREMENTS: INDICATORS OF DISEASE AND CONDITIONS |
Several clinical measurements are disquisitional when evaluating overall periodontal condition. These measurements tin can be used to draw a tooth's stability and loss of support and a patient'due south degree of inflammation and pattern of disease. They as well help to establish a diagnosis, guide the development of a handling plan, and document changes post-obit active therapy. Throughout this give-and-take, references will be made to documenting this information using the clinical nautical chart obtained from the Ohio State University College of Dentistry (Fig. 7-xviii).
FIGURE 7-18. Charting periodontal findings (on a partial reproduction of the course used at the Ohio Country University College of Dentistry). This class provides a logical method for documenting periodontal findings (as well as other findings). A. The left column provides the fundamental for recording the following: fremitus is recorded every bit F as on tooth #v; mobility is denoted past 1 for tooth #2, 2 for tooth #5, and 0 (no mobility) for teeth #3 and #4. Probe depths (six per tooth) are recorded during the initial examination (initial probe depths) in the three boxes for three facial depth locations on each facial surface and three boxes for three lingual depth locations. After initial periodontal therapy has been completed, probe depths should ideally exist recorded again in four to 6 weeks. They should also exist recorded at regular periodontal maintenance therapy appointments. This permits easy comparison to identify sites that answer to treatment and those that do not respond. Bleeding on probing (BOP) is denoted past a red dot over the probe depth readings as on the facial surfaces of teeth #two (mesial, midfacial, and distal), #iii (distal), and #5 (mesial and distal) and lingually on all mesial and distal surfaces. Gingival margin position is recorded as numbers in ruby-red on the root of teeth as follows: +one (1 mm apical to the CEJ) on the facial of teeth #2 and #iii, +2 on the facial of tooth #5, –1 (i mm occlusal to the CEJ) on the lingual of teeth #three and #4, and 0 (located at the level of the CEJ) on all other surfaces. Furcation classes are seen as ruby-red triangular shapes (incomplete, outlined, or solid). Grade I involvement is axiomatic on the midfacial of tooth #iii. Class II involvement is noted midfacial on # 2, also equally on the mesial (from the lingual) on # ii, and the distal (from the lingual) on #three. Class Three involvement is noted on a mandibular molar discussed below. Loss of attached gingiva (mucogingival defect) is recorded as a red wavy line seen on the facial of tooth #5. B. A mandibular molar (#30) showing a course Iii furcation evident from the facial and lingual views. Note that the triangle point is directed up toward the furcation in the mandibular curvation simply was directed down toward the furcation in the maxillary curvation every bit shown in (A). C. Adding of plaque index % and BOP %. The plaque alphabetize % tin be calculated by dividing the number of surfaces with plaque by the total number of surfaces (four per tooth). When considering only the iv teeth in this effigy, nine surfaces had plaque divided by 16 possible surfaces = 56%. The BOP % is the number of tooth surfaces that bleed on probing divided past the full number of surfaces (six per tooth). When considering only the iv teeth in this figure, 14 surfaces bled divided by 24 full surfaces = 58%.
Description
A. TOOTH MOBILITY
Tooth mobility is the movement of a molar in response to applied forces.22 Teeth may get mobile due to repeated excessive occlusal forces, inflammation, and weakened periodontal support (oftentimes associated with a widened periodontal ligament infinite as noted on radiographs). The healthy periodontal ligament is well-nigh 0.25 mm wide, decreasing to but 0.1 mm with avant-garde age. When a tooth is subjected to forces from chewing (mastication) or bruxism (grinding), movements are minimal at the rotational middle of the tooth root (cervicoapically) and greater at either the cervical or apical end of the root. Thus, at that place is a functional difference in the width of the periodontal ligament in these three regions. At whatsoever age, the ligament is wider around both the cervix and the noon than effectually the middle of the root, depending upon the amount of rotational movements to which the tooth is subjected. Further, the periodontal ligament of a natural tooth in occlusal function is slightly wider than in a nonfunctional tooth considering the nonfunctional tooth does not have an opposing tooth to stimulate the periodontal ligament nor bone cells to remodel.23
Injury to the periodontium from occlusal forces is known as occlusal trauma. It may contribute to subversive changes in the bone, widening of the periodontal ligament, and root shortening (resorption), all of which may contribute to increased tooth mobility. Some of the changes are reversible, meaning that the periodontium can adapt.24 Occlusal trauma is a condition that does non initiate, but may influence, the course of inflammatory periodontal disease under specific circumstances.25
1. Technique to Determine Molar Motion
To determine tooth mobility, first, stabilize the patient'south head to minimize motility. Side by side, view the occlusal surfaces and observe movement of the marginal ridges of the tooth being tested relative to side by side teeth equally yous use ii rigid instruments (such as the mirror and probe handles) to employ light forces alternating fairly rapidly first one way and then some other. Observe the tooth for movement in a buccolingual or mesiodistal management, also every bit for vertical "depressibility." Figure seven-19A and B illustrates the technique to determine molar mobility. Numbers assigned to denote the extent of mobility are presented in Table 7-ii. For simplicity, tooth mobility can exist recorded equally "0" for no mobility, "one" for slight mobility, "ii" for moderate mobility, or "3" for farthermost mobility that includes depressing the tooth. Run into Figure 7-18 for charting examples of mobility (categories 0, 1, 2, or 3).
| TABLE 7-ii | Numbers Assigned to Mobility Categories |
| Mobility Category | Clinical Observation | Magnitude |
| 0 | No observed motion | |
| 1 | Slight movement | <1 mm |
| 2 | Moderate movement | >1 mm |
| 3 | Extreme motility | Depressible |
FIGURE 7-19. Method for determining tooth mobility. A. Two rigid instrument handles are applied to the tooth to come across if it tin can be displaced either buccolingually or mesiodistally. For teeth with astringent mobility, the tooth can exist depressed or rotated (which is category three mobility). B. Technique for determining buccolingual mobility. Light, alternating (reciprocating) buccolingual forces are applied and movement observed relative to next teeth.
Description
Fremitus is the vibration of a tooth during occlusal contact. It is adamant by placing the nail of the gloved index finger at correct angles to the facial crown surface using a light force while the patient is asked to tap his or her teeth, or clench and movement the mandible from right to left (excursive movements). If definite vibration is felt, fremitus is confirmed and could be noted every bit an "F" on a patient'due south nautical chart for that tooth (as seen for tooth #5 in Fig. 7-xviii). If molar deportation is detected, functional mobility is confirmed. Functional mobility (bitter stress mobility) occurs when teeth move other teeth during occlusal part.
B. PROBE DEPTHS
Probing the depth of the potential infinite between the molar and gingiva (called the gingival sulcus or cleft) is a critical periodontal finding that is routinely performed in dental offices and may point the presence of periodontal disease.26,27 A blunt-tipped instrument with millimeter markings called a periodontal probe (Fig. 7-xx) is inserted into the gingival sulcus (seen on anterior teeth in Fig. 7-21 and posterior tooth in Fig. 7-22). In the presence of periodontal disease, this gingival sulcus may be called a periodontal pocket. Probing depth (referred to equally pocket depth if periodontal illness is present) is the distance from the gingival margin to the apical portion of the gingival sulcus. Probing depths in healthy gingival sulci normally range from one to 3 mm. A depth of greater than 3 mm is a possible cause for business organization. All the same, if gingival tissues are overgrown (equally may be seen during tooth eruption, or as a side effect from some medications), a pocket depth reading of four mm or greater (chosen a pseudopocket) may be present even in the absence of periodontitis. On the other manus, if there is gingival recession where the gingival margin is apical to the CEJ, at that place may exist shallow probing depths in the presence of truthful periodontal disease. Therefore, the critical determinant of whether periodontitis has occurred is measured by the amount of attachment loss (to be described shortly).
FIGURE 7-20. A standard, frequently used periodontal probe. To make measurements easier, at that place are dark bands at i, 2, iii, 5, 7, 8, nine, and ten mm.
Description
Effigy 7-21. Periodontal probe in place in the gingival sulcus. Sequence of probing technique from the mesiofacial aspect of tooth #half dozen to the distofacial aspect of molar # viii. (A), (B), (D), and (Due east) demonstrate the alignment of the probe confronting the proximal, tapering crown contours. Note that the probe is angled toward the proximal surface with enough buccolingual lean to engage the most interproximal aspect without catching on tissues. C. Midfacial probing. Discover that the depth of this midfacial sulcus is ane mm deep, and the tissue is then thin that the probe can be seen through it.
Description
FIGURE 7-22. Periodontal probe placement technique on models. A. Buccal view: Technique for facial (or lingual) probe placement. The probe is guided along the tooth surface, and care is taken not to engage the sulcular gingival tissues. B. Palatal view: Interproximal probe placement. The probe is angled slightly distally on the mesial surface of tooth #three as information technology is guided along the tooth surface, so it is non impeded by the interproximal papilla. Although not hands appreciated from this view, it is too angled 10 to 15 degrees to attain the nigh direct proximal area.
Description
1. Probing Technique
The intent is to probe advisedly into a sulcus only to the attachment, although in reality the probe normally impinges on some of the zipper, even in health. The probe should exist "walked around" the tooth with a light forcefulness to ensure a tactile sense and to minimize probing beyond the base of the pocket. When the depth of the sulcus/pocket has been reached, resilient resistance is encountered. The probe should be angled slightly toward the crown or root surface to prevent information technology from engaging or being impeded past the pocket wall (seen all-time midfacially in Fig. 7-22A). Probing depths are generally recorded as the deepest measurement for each of the six areas around each molar. On the facial surface, iii areas are recorded while moving in very pocket-size steps inside the sulcus starting in the distal interproximal, stepping around to the midbuccal, and finally stepping around to the mesial interproximal (seen when probing the facial surface of molar #vii in Fig. seven-21 from B to C to D). Interproximally, when the teeth are in proximal contact, the probe should progress toward the contact until it touches both adjacent teeth earlier line-fishing it approximately ten to xv degrees buccal (or lingual) to the tooth centrality line (seen near clearly in Figs. 7-21A and D and 7-22B). When there is no adjacent tooth, the probe is not angled. The three facial readings to record are the deepest readings for mesial interproximal, midbuccal, and distal interproximal. Similarly, 3 areas are recorded while probing effectually the palatal or lingual aspects of the molar.
C. GINGIVAL MARGIN LEVEL (GINGIVAL RECESSION OR NONRECESSION)
Before any periodontal affliction has occurred, the gingival margin level of a young healthy person is slightly coronal to the CEJ, which is the reference betoken. If the gingival margin is apical to the CEJ, there has been gingival recession, and the root is exposed (seen most evidently in Fig. vii-12B).
By convention, the following denotes the gingival margin level:
- Negative (−) numbers announce that the gingival margin is coronal to the CEJ. Normally, after tooth eruption is complete, the gingival margin is slightly coronal to the CEJ (about 1 mm on the labial and lingual aspects and about 2 mm interproximally). If the gingival margin is more coronal to the CEJ than those dimensions, in that location is an excess (overgrowth) of gingiva or the molar is partially erupted.
- Zippo (0) denotes that the gingiva is at the CEJ. There is no gingival recession.
- Positive (+) numbers announce recession (the gingival level is apical to the CEJ).
1. Technique to Determine the Gingival Margin Level
When recession has occurred, the altitude between the CEJ and the gingival margin can exist visually measured with the periodontal probe. If the gingival margin covers the CEJ, the distance from the gingival margin to the CEJ may exist estimated by inserting the probe in the sulcus and feeling for the CEJ. The junction between enamel and cementum can usually be felt with the probe, but if this junction is difficult to observe or is subgingival, the probe should be aligned at a 45° angle. Gingival margin levels are charted as "0" (margin is at the CEJ) or a "+" number (apical to the CEJ or recession) or a "–" number (coronal to the CEJ), in cerise on the roots nigh the CEJ as seen on the chart in Figure 7-18.
D. CLINICAL Zipper LOSS (SAME AS CLINICAL Zipper LEVEL)
Clinical attachment loss (clinical attachment level) refers to the distance from the CEJ to the apical extent (depth) of the periodontal sulcus. It is a measurement that indicates how much support has been lost and is, therefore, a critical determinant of whether periodontal affliction has occurred.
ane. Technique to Determine Clinical Attachment Loss
Add the probing depth and the gingival margin level measurements together to obtain the clinical attachment loss. A patient with a 3 mm pocket and a gingival level of +2 (i.e., 2 mm of recession) has 5 mm of attachment loss. A patient with a 3 mm pocket and a gingival level of −2 mm (the gingiva covers the CEJ by 2 mm) has but one mm of zipper loss. Report the instance of clinical attachment calculation on the tooth in Effigy 7-23 where the sulcus depth is ane mm (Fig. 7-23A) and the gingiva has receded 1 mm (+ane mm loss in Fig. 7-23B), then the total attachment loss is +2 mm. Clinical zipper loss tin be severe even with minimal pocket depths if there is considerable gingival recession. On the other paw, there may be no attachment loss even with deep pockets if pseudopockets are present, that is, pockets due to an enlargement of gingiva perchance caused by plaque accumulation side by side to ill-plumbing equipment restoration margins, as a side effect of sure medications, or due to hormonal changes.
Effigy 7-23. Measurements to determine clinical attachment loss (level). A. Showtime, the sulcus is probed (at ane mm). B. Adjacent, the level of the gingiva is determined with a positive number indicating gingival recession (at +i mm from the dotted line, which is the CEJ). When the two numbers are added together, the amount of attachment loss is determined. In this instance, the probing depth of 1 mm and the gingival level of + 1 (ane mm recession) issue in an zipper loss of 2 mm.
Description
Periodontists too make interproximal measurements of the gingival margin level that is a more challenging task. The severity of periodontal affliction tin therefore be accurately adamant at the 6 sites around each molar by measurements.
!E. Haemorrhage ON PROBING
Haemorrhage on probing occurs when bacterial plaque affects the gingival sulcular epithelium, resulting in inflammation in the underlying connective tissue. Bleeding visible from the gingival margin after probing is an important indicator of inflammation (Figs. seven-24A and B and 7-10B and D).
FIGURE 7-24. Clinical example of probe placement and bleeding on probing (BOP). A. Midlingual (midpalatal) probe placement on molar #13 showing 3 mm sulcus depth. B. Mesial probe placement on molar #13 probed into the lingual embrasure. Note a 5 mm pocket at the site, which shows BOP.
Description
1. Technique to Document Bleeding on Probing
When bleeding is noted later on probing several teeth, teeth that exhibit bleeding can be recorded at each probing site on the chart as a red dot above the probe depth. The percentage of sites that bleed can be calculated by dividing the number of bleeding sites by the number of total sites (where total sites equal the number of teeth present times six probe sites per tooth). Bleeding sites are charted in Figure seven-18, and a percentage has been calculated for four teeth.
!F. FURCATION INVOLVEMENT
A furcation is the branching point betwixt roots on a multirooted tooth. In the absence of existing or previous periodontal disease, furcations cannot be clinically probed because they are filled in with bone and periodontal attachment. With advancing periodontal affliction, however, attachment loss and bone loss may reach a furcation area resulting in a furcation involvement. 28,29 Pockets that extend into the furcation create areas with difficult admission for the dentist and dental hygienist to clean during regular office visits and are a real challenge for patients to reach and clean during their normal habitation care. Therefore, these areas of furcation involvement readily accumulate soft plaque deposits and mineralized calculus (seen on an extracted teeth in Fig. 7-25). These deposits frequently become impossible to remove and may provide a pathway for periodontal disease to continue to progress.
Figure seven-25. Calculus in the furcation area and root depressions. This extracted tooth has mineralized deposits (calculus) in the furcation. Once disease progresses into the furcation area, admission for removal by the dentist or dental hygienist becomes exceedingly difficult.
Description
Initially, at that place may exist an incipient (initial or kickoff) furcation interest. As disease progresses into the furcation (interradicular) area, attachment loss and bone loss will begin to progress horizontally betwixt the roots. At that signal, a furcation probe (such as a Nabor'south probe with a blunt stop and curved pattern seen in Fig. seven-26B) can probe into a subgingival furcation area. It can be used to notice the concavity betwixt roots (Fig. vii-26A). The get-go sign of detectable furcation involvement is termed course I and can progress to a grade II involvement when the probe can hook the furcation roof (the part of the root forming the nearly coronal portion of the furcal surface area) every bit demonstrated in Figure 7-27A. In the most farthermost circumstances, the furcation probe may actually extend from the furcation of ane tooth aspect to the furcation on another tooth aspect. This is referred to as a through-and-through (grade III) furcation interest (Fig. 7-27B). (A summary of the grades of furcation involvement is presented afterwards in Table 7-4.)
| TABLE 7-4 | Notations for 3 Categories of Furcation Involvement |
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