Perio Reports Vol. 25, No. 7
|Perio Reports provides easy-to-read research summaries on topics of specific
interest to clinicians. Perio Reports research summaries will be included in each
issue to keep you on the cutting edge of dental hygiene science.
|Modified Manual Periodontal Probe
Many attempts at automating periodontal probing have
been made over the years, however the manual probe is still
the one used most often in practice today.
Since the manual probe is still the number-one choice of
clinicians, researchers at the Tokyo Medical and Dental
University in Japan modified a manual probe by attaching a
fiber optic sensor to record probing depths. They compared
the sensor probe to a standard manual probe for accuracy of
The fiber optic sensor mechanism is an external sheath
that covers the manual probe, adding approximately 8mm
of length. As the probe is inserted into a sulcus, the sheath
is stopped by the gingival margin and slides back as the
probe moves forward. A spring-loaded mechanism is used as
the sheath slides back. The sliding distance is detected by the
fiber optic sensor and transmitted by cable to a personal
computer outside the mouth.
This pilot study compared probing and bleeding scores
on six individuals with moderate to severe periodontitis. Six
measurements per tooth were recorded around the first
molar in each quadrant. Measurements were repeated one
week later for comparison.
Averaging all probing scores together, the manual probe
score was 3.03mm and the fiber optic probe was 3.08mm.
In pockets 7mm or deeper, the fiber optic probe scores were
not as deep as the manual probe. This may be due to pressure
buildup on the gingival margin, pushing the margin
down, thus giving a shallower reading.
Clinical Implications: New options
might become available that modify
manual probes rather than creating automated
Ishihata, k., Wakabayashi, N., Wadachi, J., Akizuki, T., Izumi, Y.,
Takakuda, K., Igarashi Y.: Reproducibility of Probing Depth Measurement
by an Experimental Periodontal Probe Incorporating Optical Fiber. J Perio
Interdental Brush Provides Patient Self-test and Plaque Removal
Gingival bleeding can be assessed between the teeth, professionally
using a periodontal probe, or by the patient using
a triangular-shaped wooden stick moved in and out from
facial to lingual four times. Self-assessment by patients of
their own gingival health provides them with feedback and a
means of cleaning between the teeth.
Researchers at the University of Zürich in Switzerland
compared periodontal probing to the use of an interdental
brush to determine if the information about bleeding, plaque
and gingivitis was similar. The test subjects were 64 consecutive
patients being seen for their semi-annual periodontal
maintenance visit with the dental hygienist. All had gingival
inflammation with at least 50 percent papillary height and
no pocket depths exceeding 4mm.
All four quadrants were tested, half with the probe
inserted 2mm into the gingival sulcus and the other half
with one pass through with an interdental brush. Rather
than using the probe on one side of the mouth and the
interdental brush on the other side of the mouth, contralateral
quadrants were assigned. Randomly assigned
quadrants were either the maxillary right and the
mandibular left or the maxillary left and the mandibular
right. The presence or absence of both plaque and bleeding
Average bleeding scores were similar for the sites measured
with the periodontal probe and the sites tested with the
interdental brush. Scores were 47 percent for the periodontal
probe and 46 percent for the interdental brush.
Clinical Implications: Correctly sized interdental brushes can be used as a reliable self-test for interproximal bleeding.
Hofer, D, Sahrmann, P., Attin, T., Schmidlin, P.: Comparison of Marginal Bleeding Using a Periodontal Probe or an Interdental Brush as Indicators of Gingivitis. Int J Dent Hyg 9:(3)211-215, 2010.
|Bacteria Cling to Periodontal Probes
In 1985 researchers reported the translocation of
Actinobacillus actinomycetemcomitans (Aa) from infected
sites to healthy sites. Although the bacteria were moved,
they were unable to survive the ecology of the healthy sulcular
environment. While inoculation is possible, suitable
growth conditions are required for successful colonization.
Dental hygiene researchers at
University of Missouri, Kansas City
compared four probes in sites 3mm
or less and sites 4mm or greater. A
total of eight probes were tested,
four in shallow sites and four in
deep sites. The probes were inserted
subgingivally, held there for two seconds
and removed directly to a vial
of transport medium and sealed
with wax. Each probe was then
processed for evaluation under a
scanning electron microscope.
Microbial samples from 80 pockets were collected and
cultured to compare shallow and deep pockets. As
expected, shallow pockets had fewer bacteria than deep
pockets. The researchers were surprised to see just how
rough the probe surfaces were. Striations around the metal
probes indicated use of a lathe in the manufacturing
process. Roughness and barbed edges were typical of the
cuts for millimeter markings. The plastic probes had
smoother surfaces than the metal probes and were made of
two identical halves sealed together. Excess plastic flashing
around the ball tip of these probes was evident.
All probes tested retained bacteria and epithelial cells.
No differences in bacteria retention were observed between
probe types in either shallow or deep pockets.
Clinical Implications: Despite the fact that bacteria and
epithelial cells cling to probe surfaces, clinical effects of
bacterial translocation have not been shown.
Holt, L., Williams, K., Cobb, C., Keselyak, N., Jamison, C., Brand, V.: Comparison of Probes for
Microbial Contamination Following Use in Periodontal Pockets of Various Depths. J Perio 75: 353-
The Future is Ultarsonic Probing
To diagnose periodontal disease, radiographs and
periodontal probing are always used. Radiographs
provide a two-dimensional image of three-dimensional
structures and require ionizing radiation.
Periodontal probing is an invasive procedure influenced
by clinician technique, force used, probe
size and topography of the pocket. Researchers are
looking for a non-invasive approach to diagnosis
that overcomes current sources of error.
Ultrasonography may be the answer.
Researchers in London used a non-invasive
20MHz ultrasonic imaging system to determine
bone and tissue levels from the facial surfaces of
three teeth in each of three pig jaws. A fourth pig
jaw was used for histological evaluation. A notch
was made on each tooth as a landmark. An ultrasonic
gel was used between the ultrasonic probe tip and
the gingival tissues on the facial surface of the tooth.
Measurements were taken through the gingival tissue
and provided 15mm X 6.25mm images within one second.
Images were captured in a computer and compared
to actual measurements of the pig jaws.
Trans-gingival measurements or "soundings" were done
with a periodontal probe from the gingival margin
through the attachment to the bone crest. Direct measurements
were taken after surgical reflection of the
tissue. Measurements and ultrasound images were
repeated to determine accuracy.
Differences between ultrasonic images were only
0.44mm. This was less than the 1mm error found
between sounding measurements and the 0.6mm
difference between surgical measurements. Within a
preset range of plus or minus 0.6mm there was good
agreement between ultrasound measurements and
direct surgical measurements.
Clinical Implications: The advantages of a noninvasive
ultrasound diagnostic technique will be a
welcome addition to clinical practice in the future.
Tsiolis, F., Needleman, I., Griffiths, G.: Periodontal Ultrasonography J Clin Perio 30: 849-
Pain on Probing
Painful probing might deter patients from continuing
on for needed periodontal treatment. Based
on published research, we know that probing the
anterior region is more painful than the posterior.
This is explained by anatomy, identifying a greater
density of free nerve endings in the anterior gingiva
compared to the posterior gingiva. Both manual and
automated probes are associated with pain and discomfort.
The level of inflammation can also influence
pain experienced during probing.
This multi-center study in Belgium evaluated
patients’ experience of pain and discomfort during
probing, scaling and root planing (SRP) and maintenance
therapy. Local anesthesia was provided in 90
percent of SRP cases, two percent of maintenance
cases and not at all for probing. Patients completed
a computer questionnaire following each clinic visit
to measure pain and discomfort.
Less than 10 percent of patients undergoing
probing reported severe pain, more than 20 percent
reported moderate pain and approximately 60 percent
reported mild pain. Just over 20 percent
reported no pain on injections, while more than 70
percent reported some level of pain with the injections.
Overall pain levels reported for SRP and
maintenance were lower than those reported for
probing. One third of the SRP group and two percent
of maintenance patients reported taking pain
medication after treatment.
This study was funded by the original developers
of Oraqix, a topical local anesthetic used in place
of injections, as justification for an alternative to
anesthetic injections to control pain associated with
probing, SRP and maintenance therapy.
Clinical Implications: Pain control options
should be considered for probing and subgingival
Van Steenberghe, D., Garmyn, P., Geers, L., Hendrickx, E., Maréchal, M., Huizar, K.,
Kristofferson, A., Meyer-Rosenberg, K., Vandenhoven, G.: Patients’ Experience of Pain and
Discomfort During Instrumentation in the Diagnosis and Non-Surgical Treatment of
Periodontitis. J Perio 75: 1465-1470, 2004.
Pain on Probing Varies by Site
Depending on the amount of pressure used, probing can
be painful for some patients and some areas of the mouth
seem to be more sensitive than others.
Researchers at the University of Florida evaluated probing
pain associated with varying probing pressures using a
Florida Probe. Patients listened to an audio tape explaining
what sensations they would feel when the probe was inserted
into the sulcus. There would be the initial touch, followed by
the pressure and then the transition from pressure to pain. It
was this transition point they wanted to identify. Patients
were given a control switch to indicate when the pressure
became pain. The goal was not to see how much pain they
could endure, but rather the point at which pain began.
The 10 test subjects were periodontally healthy. Midfacial
and mid-lingual surfaces were measured for all maxillary
first molars and maxillary central incisors. Probing was
repeated weekly for three weeks. Scores for each of the three
visits for each person were similar and were combined to give
a single mean for each surface for each patient. Scores ranged
from 14 to 182 grams of pressure. The pain tolerance was
more than four times greater for some patients than others.
It is apparent from this small pilot study that setting an
average probing pressure for all patients will not take into
consideration the variations between patients, nor the variations
between sites within the same mouth. No reasons for
these differences were given.
Clinical Implications: When probing, incisors are more sensitive than molars and facial surfaces are more sensitive
than lingual surfaces.
Heins, P., Karpinia, K., Maruniak, J., Moorhead, J., Gibbs, C.: Pain Threshold Values During Periodontal Probing: Assessment of Maxillary Incisor and Molar Sites. J Perio 69: 812, 1998.