Risk Assessment in Periodontal Diagnosis and Treatment Planning: The Fundamental Importance of Probing

Management of adult periodontitis has undergone considerable change in the past decade. As understanding of the pathophysiology underlying the clinical course of the disease has broadened, so has our approach to diagnosis and treatment. The basic understanding of the disease as being infectious in nature, with a critical involvement of the host inflammatory response, is now being emphasized (Figure 1). The role of inflammatory mechanisms as related to the bacterial component is assuming an increasingly more important role.1-3 Basic research on the molecular level is beginning to reveal more of the complex interplay of host mechanisms comprising the development of the classical lesion, and chemotherapeutic strategies now target both the infection and the host response.4,5

Figure 1. Periodontitis is infectious in nature with a critical involvement of the host inflamatory response.

This heightened understanding of the importance and nature of the host response is changing the conceptualization of the temporal and somatic nature of the periodontal diseases. Long-term clinical studies characterized by measuring data longitudinally at individual sites has led to the concept of “risk assessment” as an essential part of patient evaluation.⁶ Risk assessment evaluation on a tooth-by-tooth basis affords the clinician the opportunity to more predictably prognosticate the onset of future attachment loss, or “disease activity.” This, in turn, allows for better treatment-planning decisions for both periodontal management and restorative/prosthetic considerations. The first step in this process is gathering information about the status of the periodontium at the time of presentation. Both clinical and radiographic data must be obtained.

The concept of disease activity (apical migration of attachment apparatus, loss of alveolar bone) has characterized the contemporary thrust of periodontal risk assessment in treatment planning for periodontal therapy. The goal is not only to treat those sites undergoing attachment loss, but also to recognize and manage those sites in imminent danger of experiencing disease activity. Because relatively few sites are “active” at any given point in time,7 and fully one third of all periodontal disease is recurrent and/or refractory,8 these determinations take on considerable importance. Discussion of assigning risk is often confused by ambiguous terminology and differences between populations under study.9 The many terms such as risk factor, risk predictor, risk marker, and risk indicator tend to be misleading and confusing to the clinician during treatment planning. Assigning a prognosis for specific sites or teeth can be simplified at chairside by simply noting the various “risks” that relate to the local situation and that particular patient.

There are a number of risk factors for periodontal disease that have been universally identified. These include age,¹⁰ history of previous disease,11 genetic predisposition,12 systemic diseases such as HIV infection, osteoporosis, and others.13-16 Of particular importance, patient compliance,17 smoking,18 and diabetes mellitus19 have been extensively documented as risk factors for periodontitis. Anything that interferes with the host response must be considered a risk, for example immunosuppressive drugs.20 The literature is replete with articles about development of risk profiles for the disease.21-24

Figure 2. Research studies use techniques that correlate changes in crevicular fluid enzymes to attachment loss or imminent disease activity.

In addition to the risk factors mentioned, the considerations of vital interest to the clinician are those which can be used in a clinical setting. Of significance are the findings associated with attachment loss or future attachment loss. There is a considerable amount of research ongoing to attempt to identify “markers” for disease activity. These can include biochemical or inflammatory mediators produced by the host as part of the biologic response to the bacterial insult. There are techniques currently being used in research studies that correlate changes in crevicular fluid enzymes to attachment loss or imminent disease activity (Figure 2). These enzymes are usually measured in the gingival crevicular fluid.25-29 Prognostic tests identifying putative periodontal pathogens at specific sites are available.30-31 They have not, however, been shown to be prognostic for attachment loss.32 Pathogenic bacteria are necessary for the development of periodontal lesions, but not sufficient without the interaction of the host inflammatory response. Bacterial determinations may prove important as an endpoint to determine when adequate care has been provided.

PERIODONTAL PROBING

Figure 3. Periodintal probing is an essential clinical technique for monitoring attachment loss and pocket depth.

One of the fundamentals of a periodontal examination is periodontal probing. It is an essential clinical technique for monitoring attachment loss and pocket depth. The data collected are used in risk assessment determinations and to gauge disease progression (Figure 3). The visualization of bleeding upon probing is pathognomonic for an inflammatory condition. The literature, however, does not indicate that bleeding upon probing is a good indicator for disease activity or ongoing attachment loss.33,34 While bleeding upon probing is not an accurate indicator for disease activity as a stand-alone diagnostic/prognostic test,35 20% of pockets that bleed successively upon two to three probings will likely become disease active at some point.36,37 Regardless of the implications of bleeding upon probing in terms of future attachment loss, it does signify a departure from normal, with all the histological changes consistent with inflammation, and therefore, should be treated.

It is generally recognized that certain inherent inaccuracies exist in probing, including variations in force, direction, and probe design.38,39 It has been reasonably well established that a constant pressure probe set between 15 and 20 g of pressure is the most reproducible technique, minimizing inter-operator differences.40,41 To this end, computerized, controlled force probes have been developed for both research and commercial distribution.42,43 Some examples of these newer devices that are commercially available include the following:

•The Florida Probe  (Florida Probe Corporation) (Figures 4 and 5) has been widely used in clinical research trials for more than 10 years.42,44,45 It has been shown to be very accurate and reproducible, measuring attachment levels from a fixed point, usually the occlusal/incisal surface. The unit is operated by a foot control, and the findings are shown on a monitor as the probing progresses. This device has become a standard in clinical trials where precise duplication of findings are required and attachment loss measurements must be standardized.

•The STM Probe (Professional Dental Technologies) is a recently introduced automated constant pressure probe utilizing disposable handpiece inserts (Figure 6). The unit audibly announces probe measurements for the patient to hear, as the operator moves around the mouth. Bleeding points are audibly announced, as well. The small unit is operated by a rechargeable battery, and so is easily carried between operatories (Figure 7). The operation is activated by the depression of the probe in the sleeve as it enters the pocket (Figures 8 and 9), without the need for foot control. It provides a printout of bleeding points and probing depths and is proving to be extremely useful for charting by dental hygienists.

Although not used for measuring pocket probing depths, a device has been introduced commercially that allows the operator to visualize the root surface and soft tissue walls within a periodontal pocket. The DV2 Perioscopy System (Dental View Co) (Figures 10 and 11) is a miniature fiber-optic endoscope that feeds an image of the wall of the pocket to a color monitor. This allows for a number of observations, such as residual calculus on a root surface, fractures, perforations in furcations, etc.46

DISCUSSION

Figure 12. Probing can help confirm the anatomy of periodontal defects observed on two-dimensional radiographs.

The value and importance of regular probing for attachment changes is a vital part of risk assessment. It provides the clinician with basic information about the clinical status of the periodontium. Even though pathogenic plaque accumulation is a clear risk factor and prerequisite for periodontitis,47-49 elevated plaque indices have not been shown to be predictive for disease activity.50 Probing measurements continue to be the benchmark for determining progression or stability of periodontal disease.51 In addition to sulcus depth, measurement of attachment level and tissue inflammation are obtained. Probing can help confirm the anatomy of periodontal defects observed on two-dimensional radiographs (Figure 12). In addition, information is gained about the risk of future attachment loss. These clinical assessments can be made with manual probes (Figures 13a and 13b), as well as automated/computer-linked probes.

CONCLUSION

It is apparent that probing the periodontal patient is, at the very least, a critical part of treatment planning and risk assessment, as it provides the clinician with the basic information needed to critically assess the periodontal status of the patient for appropriate treatment planning. For the clinician, probing depth and attachment loss are important measures of disease severity. These terms denote the history of the disease’s effect on the attachment apparatus, as visualized, for example, by radiographs (Figure 12). Disease severity is absolutely critical in treatment planning, not only for periodontal management but for determining the aesthetic and functional success of future restorative and prosthetic follow-up.

Risk assessment covers many areas of concern, but for treatment planning and monitoring purposes periodontal probing as a specific indicator of gingival inflammation and a measurement for attachment loss is an essential part of the diagnostic process.

References

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Dr. Bader practices periodontics and implant dentistry in Concord, Mass. He currently serves as lecturer in postgraduate periodontology at the Harvard School of Dental Medicine. He is a fellow of the American College of Dentists, International College of Dentists, and American Academy of Osseointegration. He has published in the Journal of Dental Research, Journal of Periodontology, Journal of Clinical Periodontology, and American Journal of Dentistry.