Periodontal probe

periodondal probe

1. Periodontal Probe BY: DEBASIS MITRA Final year PG student GNIDSR,KOLKATA

2. Contents Introduction History Characteristics Uses Generations Probing technique Conclusion References

3. INTRODUCTION Probe – “to test” Tapered , rod like instrument , with a blunt rounded tip which is generally calibrated in millimetres.( Carranza Clinical Periodontology ,12 th edition ). Used to measure depth of pockets and determine their configuration. When measuring a pocket, the probe is inserted with a firm, gentle pressure to the bottom of the pocket. The shank should be aligned with the long axis of the tooth surface to be probed.

4. HISTORY Periodontal probe and its use was first described by F.V. Simoton of the University Of California, San Francisco in 1925 .He proposed flat probes 1 mm wide, 10 mm long, and notched every 2 mm. Miller suggested probing of all pockets and recording their depth and putting this information on diagnostic chart. Orban (1958) described the periodontal probe as “the eye of the operator "beneath the gingival margin.

5. Goldman et al. stated that "Clinical probing with suitable periodontal instruments such as the Williams calibrated probe is a prime necessity in delineating the depth, topography and character of the periodontal Pocket “. Glickman stated that "The probe is an instrument with a tapered rod-like blade which has a blunt and rounded tip.“ The probes most commonly used today were developed by Ramfjord in 1959. He stated that the probes in use at that time were too thick to probe narrow clinical pockets and designed a round probe with a tip diameter of 0.4mm.

6. In 1967, Clavind and Loe reported the results of a research protocol in which they used a periodontal probe tip that was 0.8 mm in diameter with a 10 gm force. In 1992, B. L. Pihlstrom created a classification of periodontal probes. In 2000, Watts extended the classification system to include a fourth and fifth generation of probes.

7. Rationale behind periodontal probing Detect and measure loss or gain of attachment level TO Determine the extent of previous or ongoing disease activity AND Assess the effect of ongoing treatment.

8. CHARACTERISTICS OF A PROBE It should be tissue friendly and not traumatize the periodontal tissues during probing . It should be suitable as a measuring instrument . It should be standardized to ensure reproducibility, particularly with respect to recommended pressure(20 gms ). It should be suitable both for use in clinical setting where precise data documentation is required and on individual patient basis, and for screening purposes, as in epidemiology . It should be easy and simple to use and read.

9. PROBE DIAMETER There are numerous reports using various tip diameters (0.4, 0.5, 0.6, 0.8 and 1.0 mm). Van der Velden and Jansen (1981 ) indicated that the pressure applied to the probe moved the probe along the tooth until an opposing pressure prevents further movement. Inflammation reduces the ability of the tissues to exert pressure opposing that exerted by the probe. Keagle and Garnick (1989) - Probe diameter of 0.6 mm discriminated best, the different levels of gingival inflammation and health . It is recommended that, to measure the new sulcus depth, but not to penetrate the long junctional epithelium, forces of 20 grams should be used with a probe tip diameter 0.6 mm.

10. USES To measure sulcus and pocket depth To measure clinical attachment level To determine width of attached gingiva To assess the presence of bleeding or purulent exudate To detect and quantify furcation in molar tooth specially by Nabers probe. To determine the biotype of gingiva Determination of sulcus /pocket depth Width of attached gingival is measured Bleeding appears after few seconds Nabers probe is used to detect furcation in maxillaty molar region

11. To measure the size of oral lesions To detect gingival recession To detect edema . Side of the probe is used to apply pressure on the swelling Measuring recession

12. Classification of probes Periodontal probes are classified as 1 st generation probe 2 nd generation probe 3 rd generation probe 4 th generation probe 5 th generation probe Ref: Pihlstrom et al ,1992 and Watts et al ,2000 Philstrom Watts

13. 1st Generation Probes Advantages Tactile sensitivity Easily available and inexpensive. Even in presence of sub gingival calculus probe can be inserted with little navigation by the operator. Tip is rounded to avoid tissue trauma. Color coded for faster and easier identification of readings. Conventional Manual Probe Disadvantages Probes are heavy Probing force is not control Errors during visualization Composed of either stainless steel or plastic. The design of the working ends of manual probes are either tapered, round, flat, or rectangular with smooth rounded ends and are calibrated in millimetres at various intervals. Probes have either straight or curved working ends.

14. TYPES OF PERIODONTAL PROBES . A. Marquis color-coded probe. Calibrations are in 3,6,9,12mm sections. B. UNC-15 probe, a 15-mm long probe with millimeter markings and color coding at the fifth, tenth, and fifteenth millimeters. C. University of Michigan “O” probe, with Williams markings (at 1, 2, 3, 5, 7, 8, 9, and 10 mm). D. Michigan “O” probe with markings at 3, 6, and 8 mm. E. World Health Organization (WHO) probe, which has a 0.5-mm ball at the tip and millimeter markings at 3.5, 8.5, and 11.5 mm and color coding from 3.5 to 5.5 mm

15. William probe Charles H.M. Williams in 1936 introduced graduated periodontal probe. It is stainless steel probe with diameter 1mm ,length 13mm and blunt tip end . The probe tip and handles are enclosed at 130.8 4 and 6 mm markings are missing which minimize confusion during reading due to small size of markings. 4 mm is the upper limit of moderate Periodontitis and 6 mm is considered advanced (≥ 5 mm) Periodontitis.

16. UNC 15-Probe 15mm marking Marking at 5,10,and 15 mm Probe tip diameter 0.6mm Thin shank allows access into tight fibrotic sulci. Suitable for use in deep periodontal pockets. It is preferred for clinical trials where conventional probe is required.

17. Marquis colour coded probe Calibrations are in 3mm sections to facilitate easy read out of pocket depth. Markings are 3,6,9,12mm. It is available in both straight and curved designs and has the slimmest tip.

18. Michigan O probe In an effort to increase the accuracy and reproducibility of readings and to improve efficiency, Michigan “O” probe was introduced by Ramfjord . It was attempted to make this probe as thin as possible and to give it the most versatile angulation for universal probing of periodontal pockets Markings are at 3 ,6, and 8 mm

19. Goldman Fox Probe There will be markings at 1,2,3,5,7,8,9,10 mm. There will be no colour coding(black bands) . Flat working end for easier insertion in facial and lingual surfaces. It is used to assess periodontal pocket depths, attachment levels, anatomy configurations and gingival bleeding.   Flat shank does not allow easy access into tight fibrotic pockets.

20. CPITN probe First described by WHO and FDI in 1978 and introduced by Jukka Ainamo , David Barmes , George Beagrie in 1982. It is recommended for screening and monitoring patients using CPITN index. Purposes- 1.measurement of pocket depth 2.detection of subgingival calculus The FDI /WHO Joint Working Group has advised the manufacturers of CPITN probes to identify the instruments as CPITN–E (epidemiologic) , which have 3.5-mm and 5.5-mm markings, and CPITN–C (clinical), which have 3.5-mm, 5.5-mm, 8.5-mm, and 11.5-mm markings. CPITN probes have thin handles and are lightweight (5gm). The probes have a ball tip of 0.5 mm, with a black band between 3.5 mm and 5.5 mm, as well as black rings at 8.5 mm and 11.5 mm. Advantages :- a. Ball tip for patient comfort. b. Colour coded from 3.5-5.5; easy to read markings. c. Thin shank allows access into tight fibrotic sulci.

21. FURCATION PROBE The Nabers probe has curved workings ends and a blunt tip to facilitate detection and classification of furcations ie , degree of penetration into the furca . Although the conventional straight probes can still be used, most clinicians find the Nabers probe to be superior for furcation areas. These probes can be color-coded or without demarcation. There are markings at 3,6,9,12 mm.There are presence of colour coding between 3-6 and 9-12mm . Advantages:- Ideal for detection of mesial and distal furcations in maxillary molars; markings are helpful . THREE TYPES:1N,2N(COLOUR CODED),3N PROBE

22. LL 20 Probe(Hu- Friedy USA) A conventional manual probe marked in increments of 1 mm upto 20mm Tip diameter 0.5mm Thick black markings at 4 , 9 ,14 and 19 mm. Ref : Mayfield et al ,1996

23. PLASTIC PROBE The newer plastic Color Vue version of probe has become very popular now-a-days. These probes allow clinicians to obtain more efficient and accurate readings, resulting in more time for themselves and patient education by providing better visibility and comfort .   Advantages : - a. Vivid yellow tip and black markings provide increased intraoral visibility for faster and more accurate assessments. b. Flexible, rounded tip ensures greater patient comfort and acceptability. c. Convenient twist-on design allows for easy replacement of worn tips and use of larger diameter, ergonomic handle. d. Safe for use with implants Plastic probe: Colorvue (Hu- Friedy , Chicago).

24. Biotype probe(Hu- Friedy’s,COLORVUE ) BIOTYPE PROBE TIPS ARE DESIGNED TO BE USED UPTO 30 TIMES.THE HIGH QUALITY RESIN TIPS ARE SAFE AND GENTLE ENOUGH TO USE ON ALL PATIENTS,INCLUDING PATIENTS WITH IMPLANTS.

25. COMPARISON OF DIFFERENT TYPES OF PERIODONTAL PROBES

26. Round tip with a single bend

27. 2nd Generation Probes Constant force controlled pressure probes They are pressure sensitive probe. Second generation probes were developed in an effort to standardize and quantify the pressure used during probing. Scientific literature that demonstrated probing pressure should be standardized and not exceed 0.2 N/ mm 2 led to the development of these probes. According to Hefti et al., some research “identified a positive correlation between probing force and depth of probe penetration”. Weinberg et al. stated that controlled force of 20 to 25 grams probe during probing reduced examiner error. The second generation probes did not have electronic data collection.

28. Advantages of second generation probes :- Standardization of probing forces. Comfortable to the patient. Constant pressure. Disadvantages of second generation probes:- Probe tip may pass beyond the junctional epithelium in inflamed sites. Reading has to be performed manually. No computer storage of the data.

29. 1 st pressure sensitive probe By Gabathuler and Hassell in 1971 Hand-piece component T ip diameter :0.65 mm Markings 3,6 and 9mm Probing force: 0.25±0.09N Electric component : Small piezoelectric pressure sensor attached to non-probing end of probe tip Probing forces were transferred from the tip to sensor via a piston and the electric potential generated in the piezo element was amplified stored or converted into a printer signal.

30. Armitage et al(1977) developed 16 gauge transparent catheter around a needle shaft with a spring around it. Needle shaft could be inserted into the catheter determine by force of spring . Any type of probe could be inserted into the shaft. Force calibration : 0.15 -0.35 N in 0.05 increments

31. Pressure probe By v ander Velden and de Vries in 1978 Metal cylinder with a diameter of 1mm and movable piston of diameter 0.63 mm Probing force: 0.1 -0.5 N Probing pressure : 0.32 N/square mm

32. Electronic pressure sensitive probe By Polson et al in 1980 Hand piece of pressure-sensitive periodontal probe, A. Periodontal probe tip inserted into a chuck at front of hand piece. B. Protective plastic sheath. C, Pivot. D. Air gap. E. Coil of electromagnet. Prior to insertion of probe tip into sulcus, the air gap is closed: when the preset probing force is reached, the air gap opens and an audible signal sounds Yeaple probe used in the studies of dentinal hypersensitivity.(Kleinberg et al.,1994)

33. Vine Valley probe Same as electronic pressure sensitive probe by P olson et al (1980) except that in it probe with which readings were made was LL 20 probe. Ref : Mayfield et al ,1996

34. True Pressure Sensitive (TPS) probe:- It is the prototype for second-generation probes . Introduced by Hunter in 1994, these probes have a disposable probing head and a hemispheric probe tip with a diameter of 0.5 mm. A controlled probing pressure of 20 gm is usually applied. These probes have a visual guide and a sliding scale.

35. 3rd Generation Probe Constant force plus computer assisted probe It minimizes the errors of second generation by using not only standardized pressure, but also digital readouts of the probes’ readings and computer storage of data. This generation includes computer-assisted direct data capture to reduce examiner bias and allows for greater probe precision. These probes require computerization of the dental operatory and can be used by clinicians and academic institutions for research .These probes reduce the errors in reading the probe, recording data, and calculating attachment level.

36. Advantages of third generation probes :- Standardization of probing forces Errors in reading the probe and transferring the data are eliminated. Print out of the data from the computer can be used for patient education. Disadvantages of third generation probes:- Tactile sensitivity is decreased. Probe may pass beyond the junctional epithelium in inflamed sites , overestimating the pocket depth. After the inflammation has resolved, probe may not penetrate beyond the junctional epithelium , leading to underestimating the pocket depth.

37. Foster Miller Probe By Jeffcoat et al in 1986 Automated detection of CEJ, better landmark than gingival margin. Components: Pneumatic cylinder Linear Variable Differential Transducer Force Transducer accelerometer probe tip The main disadvantage is that it can deem root roughness or root surface irregularities as the CEJ.

38. Florida probe The Florida Probe® (Florida Probe Corp, Gainesville, FL) was devised by Gibbs et al. in 1988 . The Florida Probe was developed following the criteria defined by the National Institute of Dental and Craniofacial Research for overcoming limitations of conventional probing.

39. Advantages: a . Constant probing force with precise electronic measurements. b . Computer storage of data. Disadvantages: a . Lack of tactile sensitivity . b. Underestimation of deep probing depths by the automated probe.

40. The system includes a probe handpiece , digital readout, foot switch, computer interface, and computer. Once the tip of the probe is inserted into the sulcus , the clinician presses the foot pedal and the system automatically records pocket depth, attachment loss, bleeding, suppuration, plaque, recession, hyperplasia, mobility, furcation, and mucogingival involvement. The probe measures 0.4mm and sleeve measures 0.9 mm, applies 15g of pressure (.2mm precision).

41. Disc Probe Stent Probe

42. Florida probe with stent Florida probe without stent

43. Toronto automated probe By Birek et al and Mc Culloh et al ,1991 Used o cclusoincisal surface as reference and measure CAL Probed with :0.5 mm Ni- Ti wire that is extended under air pressure. Angulation maintained by ±10 of a vertical position by the examiner. This probe has the advantage of an incorporated electronic guidance system to improve precision in probe angulation. The disadvantages are associated with positioning: it is difficult to measure second and third molars, and patients have to position their heads in the same place to reproduce reading.  

44. Inter probe An electronic probe using an optical encoder transduction element. flexible probe tip No pain Probing pressure: 15 gm 0.55 mm probe plastic filament The probes optical encoder handpieces uses constant probing pressure, which provides repeatable measurement of pocket depth and attachment loss.

45. 4th Generation Probe These are three dimensional probes in which sequential probe positions are measured. ADVANTAGES 1)Allow three –dimensional measurement 2)Sequential probe positions can be measured 3)Computerized storage 4)Printout can be obtained DISADVANTAGES 1)Under developed

46. Fifth generation probe Probes are being designed to be 3D and non-invasive : an ultrasound or other device is added to the fourth generation probe. Fifth-generation probes aim to identify the attachment level without penetrating it . The only fifth-generation probe available, the Ultra Sonographic (US) probe ( Glen Allen, VA), uses ultrasound waves to detect image and map the upper boundary of the periodontal ligament and its variation over time as an indicator of the presence of periodontal disease. The US probe was devised by Hinders and Companion at the NASA Langley Research Centre. To probe these structures ultrasonically, a narrow beam of ultrasonic energy is projected down between the tooth and bone from a transducer, which is scanned manually along the gingival margin.

47. Ultrasound gives more information because secondary echoes are recorded from tissue features at various depths. It appears likely that the technique also will be able to provide information on the condition of the gingival tissue and the quality and extent of the epithelial attachment to the tooth surface. This may supply valuable data to aid the clinician in the diagnosis and treatment charting of these diseases.  

48. Ultrasound waves in coupling water are focused inside of tip to a very thin beam. Crest of the periodontal ligament reflects ultrasound beam. Echoes are recorded by ultrasonic transducer and then analyzed by Computer expert system.

49. Disadvantages of fifth generation probes :- Expensive Operator needs to understand the images provided by computer. Advantages of fifth generation probes:- A non invasive probe that provides painless probing to the patient. There is no question of probe passing beyond the junctional epithelium, as the ultrasound waves detect image and map the upper boundary of periodontal ligament. Computer storage of data. Guidance path is predetermined. Provides information regarding condition of gingival tissue. US probe

50. Other non- periodontal probes Name Mode of action Calculus detection probe Detect subgingival calculus with light emitting diode by means of audible signals. Diamond Probe/Perio 2000 System Measures relative sulfide concentrations in GCF by microsensor as an indicator of gram-negative bacterial activity. Periotemp Probe Detects early inflammatory changes in the gingival tissues by measuring temperature variations in GCF, with a sensitivity of 0.1 ºC.

51. PROBING TECHNIQUE Probing is the act of walking the tip of a probe along the junctional epithelium within the sulcus or pocket for the purpose of assessing the health status of the periodontal tissues . The Walking method :- the probe is walked around the sulcus or periodontal pocket using walking stroke. The walking stroke is the movement of a probe around the perimeter of the base of a sulcus or pocket. Walking strokes are used to cover the entire circumference of the sulcus or pocket base.

52. 1.Walking strokes are a series of bobbing strokes that are made within the sulcus or pocket. The stroke begins when the probe is inserted into the sulcus while keeping the probe tip against the tooth surface . 2.The probe is inserted until the tip encounters the resistance of the junctional epithelium that forms the base of the sulcus. The junctional epithelium feels soft and resilient when touched by the probe. 3.Create the walking stroke by moving the probe up and down in short bobbing strokes and forward in 1-mm increments. With each down stroke, the probe returns to touch the junctional epithelium. 4.The pressure exerted with the probe tip against the junctional epithelium should be between 10 and 20 grams.

53. Adaptation and parallelism:- The side of the probe tip(defined as 1 to 2mm of the side of the probe) should be kept in contact with the tooth surface .The probe is positioned as parallel as possible to the tooth surface . The probe must be parallel in the mesiodistal dimension and faciolingual dimension.

54. INTERPROXIMAL TECHNIQUE When two adjacent teeth are in contact,a special technique is used to probe the area directly beneath the contact area.

55. PERI IMPLANT PROBING The results obtained with peri implant probing cannot be interpreted same as the natural teeth because : Differences in the surrounding tissues that support implanted teeth . Probe inserts and penetrates differently . - Around natural teeth, the periodontal probe is resisted by the insertion of supra- crestal connective tissue fibers into the cementum of root surface. There is no equivalent fiber attachment around implants .

56. When selecting a probe for measuring pocket depth around a dental implant, select a plastic probe. Dental implant surfaces are typically titanium and can be easily scratched or nicked, producing surface irregularities that may provide a foundation for bacterial attachment.

57. Advantages: - Can measure the level of mucosal margin relative to a fixed position on the implant. - Measure the depth of tissue around the implant. - Peri implant probing depth is often a measure of the thickness of surrounding connective tissue and correlates most consistently with the level of surrounding bone . The probing depth around implants presumed to be “healthy ” has been about 3mm around all surfaces.

58. CONCLUSION The “Gold Standard” for recording changes in periodontal status is longitudinal measurement of clinical attachment levels from the cemento -enamel junction or relative attachment level from a fixed reference point . Thus , periodontal probe still remains as a standard and a conventional diagnostic tool in spite of newer diagnostic modalities available currently . Newer developments in the field of periodontal probes provide the potential for error free determination of pocket depth.

59. REFERENCES 1.Glossary Of Periodontal Terms. 2001 4 th Edition. 2.Carranza’s Clinical Periodontology,11 th edition 3.Periobasics.com 4.Principles & Fundamental of periodontal instrumentation-6 th edition-Jill S Nield -Gehrig 5. Pihlstrom BL. Measurement of attachment level in clinical trials: Probing methods. J Periodontol . 1992;63(12 Suppl ): 1072-10773 6. Birek P, McCulloch CAG, Hardy V. Gingival attachment level measurements with an automated periodontal probe. J Clin Periodontol . 1987;14(8):472-477 . 7. Gibbs CH, Hirschfeld IW, Lee JG, et al. Description and clinical evaluation of a new computerized periodontal probe-the Florida Probe. J Clin Periodontol . 1988;15(2): 137-144. 8. L. Mayfield*, G. Bratthall , R. AttStröm Periodontal probe precision using 4 different periodontal probes Journal of Clinical Periodontology23;(20)76–82, February 1996.