Module 12: Periodontal Probes and Basic Probing Technique

The Periodontal Probe

Design of Probe Working-End

Working-end: Blunt and rod-shaped.
Cross section: Can be circular or rectangular.
Calibration: Marked with millimeter increments.

Functions of Probes

Primary Use: Findings from a periodontal probe examination are crucial for determining the overall health status of the periodontal tissues.
Analogy: Probes function as miniature rulers for conducting intraoral measurements.

Other Uses of Probes

Measuring sulcus and pocket depths.
Measuring clinical attachment levels (CAL).
Determining the width of the attached gingiva.
Assessing for the presence of bleeding upon probing.
Measuring the size and dimensions of oral lesions.
Measuring the longitudinal response of the periodontium to various treatments over time.

Millimeter Markings

Periodontal probes are universally marked in millimeter increments.
They are specifically designed to evaluate the health of periodontal tissues.
Variety: There are numerous different patterns of millimeter markings available on various probes.
Color-Coded Probes: These probes feature markings in distinct bands, with each band typically spanning several millimeters in width. For instance, a common example shows markings at 3, 6, 9, and 12 mm.
Caution: It is critical to never assume that all probes share the same pattern of millimeter markings. To accurately determine the marking pattern of any particular probe, a standard millimeter ruler can be used for verification.

Understanding Periodontal Health and Disease

Probe in a Healthy Sulcus

When a probe is inserted into a healthy gingival sulcus, the probing depth should ideally range from 1 to 3 mm.

Probe in Periodontal Pocket

A probing depth deeper than 3 mm is a clinical indicator of a periodontal pocket.

The Healthy Periodontium

Alveolar Mucosa: The unattached, movable tissue beyond the mucogingival junction.
Mucogingival Junction: The scalloped line separating the attached gingiva from the alveolar mucosa.
Attached Gingiva: The part of the gingiva that is firmly bound to the underlying cementum and alveolar bone.
Free Gingiva: The unattached portion of the gingiva that forms the soft tissue wall of the gingival sulcus. It surrounds the neck of the tooth in a manner similar to a turtleneck collar.
Interdental Gingiva: Also known as the papilla, this is the portion of the gingiva that fills the embrasure space (the area between two adjacent teeth apical to the contact area).

Healthy Gingival Sulcus

Definition: A V-shaped shallow space or crevice located between the free gingiva and the tooth surface.
Assessment: A periodontal probe is inserted into this space to objectively assess its health.
Base: The base of the sulcus is formed by the junctional epithelium (JE), which is the tissue that attaches the gingiva to the tooth.
Measurement: The sulcus depth is defined as the distance from the gingival margin to the coronal-most part of the junctional epithelium.

Periodontal Pocket

Gingival Pocket (Pseudopocket): This refers to a deepening of the gingival sulcus primarily caused by the detachment of the coronal portion of the junctional epithelium and significant swelling (edema) of the gingival tissue. There is no apical migration of the junctional epithelium or destruction of alveolar bone.
Periodontal Pocket (True Pocket): This type of pocket forms due to the apical migration of the junctional epithelium, accompanied by the irreversible destruction of periodontal ligament fibers and supporting alveolar bone.

Recap: Probing Depth

Probing depth is the specific distance, measured in millimeters, from the gingival margin to the anatomical base of the sulcus or pocket, as determined with a periodontal probe.

Basic Probing Technique: Adaptation

Adapting the Probe Tip

Contact Area: For correct adaptation, only the leading 1 to 2 mm of the side of the probe working-end, referred to as the probe tip, should be kept in contact with the tooth surface.
Throughout Stroke: It is crucial that the probe tip maintains continuous contact with the tooth surface during the entire walking stroke.

Incorrect Adaptation

The probe tip should NOT be held away from the tooth surface, as this will lead to inaccurate readings and potential tissue trauma.

Adaptation of Instrument to Tooth Surface

Critical Element: The precise placement of the working-end of an instrument in relation to the tooth surface being instrumented is a fundamental and critical element in all periodontal instrumentation.
True Angulation: A correct visual understanding of the true angulation of teeth within the dental arches is essential, as most teeth are not perfectly vertical but are often tilted. This understanding significantly assists in the correct initial placement and ongoing adaptation of the working-end on root surfaces.

Positions of Teeth

Tilting: It is important to remember that most teeth are not positioned vertically in the dental arches; rather, they are often tilted.

Adaptation to Proximal, Facial, and Lingual Surfaces

Correct adaptation images show the probe parallel to the long axis and contour of the tooth surface, ensuring the tip is in contact.
Incorrect images show the probe angled away from the tooth or not parallel, which would result in inaccurate measurements.

Recap & Practice Adaptation

Key Principle: A clear visual understanding of the true angulation of teeth in the dental arches is indispensable for the correct placement of the working-end on root surfaces.
Initial Placement: The initial placement of the working-end always begins with correct orientation to the specific tooth surface plane.
Mnemonic for Setup: The sequence for preparation is: ME (clinician's position), MY PATIENT (patient's position), MY NON-DOMINANT HAND (mirror, retraction), MY DOMINANT HAND (holding the instrument), GRASP (establishing the instrument grasp).

Parallelism

Correct: The probe should be positioned parallel, or as parallel as mechanically possible, to the root surface being assessed. This term aids in understanding correct adaptation.
Incorrect Technique: The probe is improperly positioned if it is not parallel to the root surface, leading to inaccurate readings.

Basic Probing Technique: Walking Stroke

Probing: The Act

Probing is defined as the act of systematically walking the tip of a periodontal probe along the base of a sulcus or pocket for the express purpose of comprehensively assessing the health status of the surrounding periodontal tissues.
Movement: This technique utilizes a combination of both digital (finger) and wrist-rock movements.

Probe Walking Stroke

Description: A walking stroke is a continuous series of short, rhythmic, bobbing strokes executed within the sulcus or pocket. During these strokes, the probe tip must remain in constant contact with and in alignment with the root surface.
Coverage: The walking stroke technique is employed to effectively cover the entire circumference of the sulcus or pocket, ensuring no area is missed.

Production of Walking Strokes

Insertion: Insert the probe into the sulcus/pocket and gently advance the tip along the tooth surface until a soft, flexible resistance is encountered. This resistance signifies the soft tissue base, which is the junctional epithelium.
Movement: Create a walking stroke by moving the probe tip vertically up and down in short, controlled bobbing strokes.
Increment: Move the probe laterally along the tooth surface in tiny, approximately 1-mm increments.

Important Note: The probe is NOT to be removed from the sulcus/pocket with each individual stroke. Repeatedly removing and reinserting the probe can cause unnecessary trauma to the delicate gingival tissues.

Depths Vary in a Single Area

It is very common for the base of the sulcus or pocket to exhibit non-uniform depths. A pocket's depth can often be deeper in one specific spot compared to others within the same area.

Walk the Entire Circumference

To prevent missing areas of deeper pocketing, it is imperative to walk the probe along the entire circumference of the sulcus or pocket base.

Recording Measurements

Zones: Measurements are meticulously recorded for six specific sites or zones on each individual tooth: mesiofacial, facial, distofacial, mesiolingual, lingual, and distolingual.
Deepest Reading: Only one reading, specifically the deepest measurement obtained within each zone, is recorded per zone.
Rounding: All measurements are traditionally rounded up to the nearest full millimeter.

Limitations of Measurements

Several variables can impact the accuracy of probing depth measurements:
- The precise position of the gingival margin at the time of measurement.
- Interference caused by calculus deposits or poorly contoured, overhanging restorations.
- The amount or consistency of pressure applied by the clinician during probing.
- Potential misreading of the probe calibrations due to visual error or poor visibility.

Probing Interproximal and Anterior Surfaces

Taking Readings on the Mesial and Distal Surfaces

A specialized technique is required to accurately probe the area situated directly beneath the contact area when two adjacent teeth are in contact.

Interproximal Readings

Due to the physical obstruction, it is naturally impossible to perfectly align the probe tip directly perpendicular to the base of the sulcus that lies immediately under the contact area between two adjacent teeth. The probe cannot physically fit in this manner.

Two-Step Technique for Mesial and Distal Surfaces

Step 1: Touch the Contact Area: Initially, walk the probe between the teeth until its side gently touches the contact area between the adjacent teeth.
Step 2: Tilt the Probe: From this position, slightly slant or angle the probe so that its tip is directed and reaches underneath the contact area. While maintaining this angulation, gently press downward to contact the soft tissue base of the sulcus/pocket.

Proximal Surface Assessed from Facial and Lingual

Each proximal surface (mesial and distal) is assessed from both the facial and lingual aspects to ensure full coverage.

Detailed Steps for Probing Posterior Teeth (Example from Distofacial Line Angle)

**Start Point (