专业英语 Unit 14教案

UnitFourteen

CLINICALFEATUREOFCHRONICPERIODONTALDISEASE

Chronicgingivitis

Themanifestationsofgingivalinflammationvaryconsiderablybetweenindividualsand

fromonepartofthemouthtoanother.Thisvariationreflectstheaetiologicalfactorsatworkand

thetissueresponsetothesefactors.Thisresponseisessentiallyamixtureofinflammationand

fibroustissuerepair.Whentheformerpredominates,signsandsymptomsaremoreobvious;when

thefibroustissuecomponentpredominates,clinicalmanifestationscanbemuchmoresubtleand

recognizedonlybycarefulexamination.

Inmakingadiagnosisitisimportanttokeepinmindtheappearanceofhealth,departures

fromwhichmayindicatedisease.

Clinicalfeaturesare:

1.Alteredgingivalappearance.

2.Gingivalbleeding.

3.Discomfortandpain

4.Unpleasanttaste

5.Halitosis.

Alteredgingivalappearance

Changesinappearanceareusuallydescribedaccordingtocolor,shape,size,andsurface

characteristics.

Healthygingivaearepalepinkandthemarginisknifeedgedandscalloped;astreamlined

papillaisoftengroovedbyasluice-wayandtheattachedgingivaisstippled.

Becausetheinterdentalembrasureisthesiteofgreatestplaquestagnationgingival

inflammationusuallystartsintheinterdentalpapillaandspreadsaroundthemargin.Astheblood

vesselsdilatethetissuebecomesredandswollenwithinflammatoryexudate.Theknife-edged

marginbecomesrounded,theinterdentalsluice-wayislostandthesurfaceofthegingivabecomes

smoothandglossy.Asthegingivalfibertheinflammatoryprocessthegingivalcufflosestoneand

comesawayfromthetoothsurfacesothatashallowpocketisformedbreaksupbundles.Ifthe

inflammationbecomesmorediffuseandspreadsintotheattachedgingivathestipplingdisappears.

Ifinflammationissevereitcanspreadacrosstheattachedgingivatothealveolarmucosaandso

obliteratethenormallywell-definedmucogingivaljunction.

Usuallythemostpronouncedinflammatoryswellingisseeninadolescentsandyoungadults

sothatfalsepocketingisformed.Itiscalledfalseasopposedtorealorperiodontalpocketing

whichisformedbyapicalmigrationofthecrevicularepitheliumastheperiodontalligamentis

destroyedbyinflammation.Whereseveralaetiologicalfactorscombine,e.g.plaquedeposition

pluslackoflip-sealplustheendocrinalchangesofpuberty,gingivalswelling,especiallypapillary

swelling,canbepronounced.

Ifplaqueirritationislongstandingandlowgrade,themaintissuereactionwillbefibrous

tissueproductionsothatthegingivamayremainfirmandpinkbutbecomethickenedandloseits

streamlinedshape.

Gingivalbleeding

Gingivalbleedingisprobablythemostfrequentpatientcomplaint.Unfortunatelygingival

bleedingissocommonthatpeoplemaynottakeitseriouslyandevenbelieveittobenormal;

however,unlessbleedingobviouslyfollowsanepisodeofacutetrauma,bleedingisalwaysasign

ofpathology.Itoccursmostfrequentlyontoothbrushing.Bleedingmaybeprovokedbyeating

hardfood,apples,toast,etc.Whengingivaeareextremelysoftandspongy,bleedingcanoccur

spontaneously.

Bloodmaybetastedbythepatientandmaybesmeltonthepatient'sbreath.

Ifthetissueresponseisfibrousovergrowth,thereisnobleedingevenwithvigorous

toothbrushing.

Discomfortandpain

Theseareuncommonfeaturesofchronicgingivitisandthisisprobablythemainreasonfor

thediseasesbeingoverlooked.Thegingivaemayfeelsorewhenthepatientbrusheshisteethand

becauseofthishebrushesmorelightlyandlessfrequentlysothatplaqueaccumulatesandthe

conditionisperpetuated.

Thisrelativeabsenceofpainisoneofthesymptoms,whichdifferentiatesachronic

gingivitisfromanacuteulcerativegingivitis.

Unpleasanttaste

Patientsmaynoticethetasteofblood,particularlyiftheysuckataninterdentalspace.

Unfortunatelythesensesarequicklybluntedandadisagreeabletasteisarelativelyinfrequent

complaint.

Halitosis

'Badbreath'frequentlyaccompaniesgingivaldiseaseandisacommoncauseofavisitto

thedentist.Thesmellderivesfrombloodandpoororalhygieneandmustbedistinguishedfrom

smellsfromdifferentsources.

Halitosishasanumberofcauses,bothintra-oralandextra-oral.Oraldiseaseandresidual

fooddeposits,especiallythoseofavolatilenaturesuchaspeppermint,garlic,curry,etc.,represent

themostcommoncauseofhalitosis.Pathologyoftherespiratorytract,nose,sinuses,tonsilsand

lungscancauseanembarrassingsmell,ascandiseaseofthedigestivetract.Someitemsofdiet,

e.g.garlic,areabsorbedbytheintestines,takenintotheintestinalbloodstreamandfinallyexhaled

bythelungssothattheycanbesmeltalongtimeaftertheyhavebeeneaten.Mouthodouris

commononwakingandbetweenmeals,whenitisassociatedwithfoodstagnationandreduced

salivaryflow.Metabolicdiseases,diabetesanduraemiagivecharacteristicsmellstothebreath.

Halitosiscanincreasewithage.

Chronicperiodontitis

Theclinicalfeaturesofchronicperiodontitisare:

1.Gingivalinflammationandbleeding

2.Pocketing

3.Gingivalrecession

4.Toothmobility

5.Toothmigration

6.Discomfort

7.Alveolarboneloss

8.Halitosisandoffensivetaste.

Ofthisonlypocketingandalveolarbonelossareessentialfeaturesofchronicperiodontitis.

Gingivalinflammationandbleeding

Althoughgingivalinflammationisanecessaryprecursortoperiodontitis,obvious

manifestationsofinflammationbecomelessapparentwiththeprogressofperiodontitis.

Frequentlythegingivaearepinkandfirm,thecontoursmaybealmostnormal,thereisno

bleedingoncarefulprobingandthepatientdoesnotcomplainofbleedingonbrushing.Itisas

thoughwiththedevelopmentofthepocketthediseasehasgoneunderground.

Thepresenceandseverityofgingivalinflammationdependsuponoralhygienestatus;

wherethisispoor,gingivalinflammationisevidentandbleedingofbrushing,orevenspontaneous

bleeding,isnoticedbythepatient.Whenthepatient'stoothbrushingisgoodenoughtocontrol

plaquebutwheresubgingivaldeposits,becauseofinadequatescaling,persist,thepresenceof

periodontaldiseasemaynotbeapparentonsuperficialexamination.Ifacarefulhistoryistaken

manysuchpatientsreportahistoryofpastbleedingwhichstoppedwhentheirtoothbrushing

techniqueimproved.Periodontaldestructionintheaverageadultistheproductofpastneglect,not

theresultofpresentoralhygienehabits.

Pocketing

Pocketmeasurementisanessentialpartofperiodontaldiagnosisbutmustbeinterpreted

togetherwithgingivalinflammationandswellingandradiographicevidenceofalveolarboneloss.

Theoretically,ifthereisnogingivalswellingapocketover2mmdeepindicatessomeapical

migrationofcrevicularepitheliumbutinflammatoryswellingissocommonespeciallyinthe

youngerindividualthatpocketingof3-4mmmaybeentirelygingivalor'false5.Pocketingof4mm

islikelytoindicateanearlychronicperiodontitis.

Theprecisemeasurementofpocketsisdifficultbecause:

1.Probingthepocketcanbeuncomfortableandevenpainfulifthereisfrankinflammation.

2.Pocketdepthisextremelyvariablearoundatooth.Interproximalpocketingisusually

deepestbecausethatisthesiteofgreatestplaqueaccumulation,whilepocketingonthefacial

aspectofthetoothisusuallymostshallowasthisiswherethetoothbrushmakesthegreatest

impactandmayevenproducegingivalrecession.Thismeansthatfourormoremeasurements

mayberequiredoneachtoothtogiveanaccuratepicture.

3.Wherepresentoralhygieneisgoodthegingivalcuffmaybesotightaroundtheneckof

thetoothastoresisttheinsertionofanordinaryperiodontalprobewithoutcausingpain.The

measurementofpocketsinanaesthetizedtissueoftenproducesquitedifferentresultsfrom

previousmeasurementmadeinsentienttissue.

4.Toothcontourandangulation,subgingivalcalculusorrestorations,aswellascarious

cavities,mayimpedetheinsertionoftheprobe.

Therearemanydesignsofpocket-measuringprobe,someof,whicharetoothicktoprovide

accuratemeasurementandsomeofwhicharesharpsothatthetissueispenetratedunlessgreat

careistaken.Ithasbeenshownthatpocketsofover3mmaremeasuredwithdiminishing

reliability,anditisunfortunatethatmuchperiodontalresearchisbaseduponsuchanunreliable

criterion.Sometimesapurulentdischargecanbeexpressedfromthepocketbypressureonthe

pocketwall.

Gingivalrecession

Gingivalrecessionandrootexposuremayaccompanychronicperiodontitisbutarenot

necessarilyafeatureofthedisease.Whererecessionoccurspocketdepthmeasurementisonlya

partialrepresentationofthetotalamountofperiodontaldestruction.

Toothmobility

Sometoothmobilityinalabiolingualplanecanbeelicitedinhealthy,single-rootedteeth,

especiallylowerincisors,beingmoremobilethanmultirootedteeth.Increasingtoothmobilityis

producedby,

1.Spreadofinflammationfromthegingivaintothedeepertissues

2.Lossofsupportingtissue

3.Occlusaltrauma.

Mobilityalsoincreasesafterperiodontalsurgeryandinpregnancy.Inperiodontalpathology

tissuedestructionisalwaysaccompaniedbyinflammationandfrequentlybyocclusaltrauma.

Mobility,whichisproducedbyinflammationandocclusaltrauma,isreversible,asdemonstrated

bythereductioninmobilityfollowingscalingandocclusaladjustment;mobilityassociatedwith

destructionofsupportingtissueisnotreversible.

Assessmentofmobilityforresearchpurposescanbemadeusingspecialapparatusbut

clinicalassessmentisusuallysubjective.Itiselicitedbyexertingpressureononesideofthetooth

underexaminationwithaninstrumentorfingertipwhileplacingafingeroftheotherhandonthe

othersideofthetoothanditsneighbourwhichisusedasafixedpointsothatrelativemovement

canbediscerned.Anotherwayofelicitingmobility(althoughnotassessingit)istoplacefingers

overthefacialsurfacesoftheteethwhilethepatientgrindstheteeth.

Thedegreeofmobilitymaybegradedasfollows:

Grade1.Justdiscernible

Grade2.Easilydiscernibleandupto1mmlabiolingualdisplacement

Grade3.Over1mmlabiolingualdisplacement,mobilityofthetoothupanddowninan

axialdirection.

Toothmigration

Movementofatooth(orteeth)outofitsoriginalpositioninthearchisacommonfeatureof

periodontaldiseaseandonewhichalertsthepatienttotheproblem.Abalanceoftongue,lipand

occlusalforcesmaintainstoothpositioninhealth.Oncesupportingtissueislosttheseforces

determinethepatternoftoothmigration.Theincisorsmovemostfrequentlyinalabialdirection

butteethmaymoveinanydirectionorbecomeextruded.Onceatoothmigratestheforceonthat

toothchangesandthismaypromotefurtherstressandfurthermigration.Ifanupperincisor

migrateslabiallythelowerlipmaycometolielingualtotheincisaledgeofthetoothandproduce

furthermigration.

Discomfort

Oneofthemostimportantfeaturesofchronicperiodontitisisthealmosttotalabsenceof

discomfortorpainunlessacuteinflammationsupervenes.Thisisoneofthemaindistinctions

betweenperiodontalandpulpdisease.Discomfortorpainonpercussionofthetoothindicates

someactiveinflammationofthesupportingtissues,whichisatitsmostacuteinabscessformation

whenthetoothbecomesexquisitelysensitivetotouch.Sensitivitytohotandcoldissometimes

presentwhenthereisgingivalrecessionandrootexposure.Indeedonecommonclinical

experienceistheappearanceofsensitivity,especiallytocold,whenrootsoncecoveredincalculus

arecleaned.Onoccasionpulppathologymaybeacomplicationofadvancedperiodontaldisease

andseverepainmaythendevelop.

Alveolarboneloss

Resorptionofalveolarboneandtheassociateddestructionofperiodontalligamentarethe

mostimportantfeatureofchronicperiodontitis,andtheone,whichleadstotoothloss.Thereis

considerablevariationinboththeformandrateofalveolarboneresorptionandinconstructinga

treatmentplantheamountofboneloss,therateatwhichresorptionisprogressingandthepattern

ofbonelossneedtobeaccuratelyestablished.Radiographicexaminationisanessentialpartof

periodontaldiagnosisandwithcertainlimitationsprovidesevidenceofthealveolarboneheight,

theformofbonedestruction,thewidthoftheperiodontalligamentspaceandthedensityof

cancelloustrabeculation.Serialradiographstakenoveraperiodoftimecanprovideinformation

abouttherateofboneloss.However,radiographicexaminationwithoutcarefulclinical

examinationcanbeverymisleading.Aperiodontaldiagnosiscannotbemadefromradiographs

aloneasthereisnowayofdistinguishingontheradiographpastbonedestructionfromcurrent

boneresorption.

Becausetheimagesofthefacialandlingualplatesofbonearelargelyobscuredbythe

denseimageofthetooth,diagnosisdependsuponobtainingaclearimageoftheinterdentalbone.

CarefulangulationoftheX-raybeamandastandardizedroutineofexposureandprocessingthe

radiographicfilmisessential.

Thefirstradiographicsignofperiodontaldestructionislossofdensityofthealveolar

margin.Thisismostclearlyseenbetweenposteriorteethwhereinhealththebroadinterdental

septumprojectsadenseandwell-definedimageofthealveolarmargin.Theimageofthenarrow

interdentalseptabetweenanteriorteethislesswelldefinedinhealthandearlypathological

changesarelesseasytosee.Withcontinuingboneresorptiontheheightofthealveolarboneis

furtherreduced.

Evencorrectlyangulatedtheradiographsmaynotdisclosethetruestateofinterdental

resorption,e.G.Aninterdentalcraterbetweenmolarscanbemaskedbytheimagesofthefacial

andlingualwallsofthedefect.Bonedefects,whichlieoverthefacialorlingualaspectsofthe

teeth,e.G.Marginalgutters,maybecompletelyobscuredandrevealedonlywhenflapsareraised

atsurgery.

Moreover,distinguishingbetweenfacialandlingualdefectsmaynotbepossiblefrom

radiographicevidencealone.Tworadiographstakenatslightlydifferentanglesoftenreveal

defectsundetectedbyone.Thisisespeciallytrueinthediagnosisoffurcationdefects.Theseare

usuallyrevealedbyradiographicexaminationbuttheexactformofthedefectmaynotbe

discernible.Thethickpalatalrootofanuppermolarmaymaskatrifurcationdefect.Wideningof

theperiodontalspaceinthefurcationprovidesevidenceofanearlylesion.Wideningofthe

periodontalspaceononesideorallaroundatoothfrequentlyindicatesexcessiveocclusalstress.

Thisissometimesaccompaniedbywideningorfunnellingofthecoronalaspectofthesocket.

Alldeparturesfromthenormalradiographicappearancemustbecheckedagainstother

clinicalfeatures,inparticularpocketdepthandmobilitypatterns,andifthesedonotcorrespond

reexaminationshouldbecarriedout.Clinicalfeaturestakentogethershouldmakeareasonablefit,

whichshedslightonboththepathologicalconditionanditsaetiology.Thus,whereradiographic

examinationofamobiletoothrevealsthatthesupportingboneisvirtuallyintact,careful

examinationoftheocclusionisessential.Theremustalwaysbeanidentifiablereasonforany

pathologicalchange.

Halitosisandoffensivetaste

Anoffensivetasteandsmellfrequentlyaccompanyperiodontaldiseaseespeciallywhenoral

hygieneispoor.Acuteinflammation,withtheproductionofpus,whichexudesfrompocketson

pressure,alsocauseshalitosis.Asourceofconstantsurpriseisthelackofawarenessofaffected

individualsandtheirspousestothepowerfulfetor,whichlikeamalignantwindescapesfromtheir

mouthswhentheyspeak.Lackofsensibilityandunconcernaboutdentalhealthseemtogohand

inhand,andaspatientcooperationisessentialtothesuccessofperiodontaltreatmentthis

sensibility,orlackofit,canprovideacluetoprognosis.

Diagnosis,prognosisandtreatmentplan

Makingadiagnosis

Thediagnosisshouldnotbelimitedtogivinganametothecondition.Ifperiodontaldisease

istobetreatedanditsrecurrenceprevented,adiagnosisshouldincludetheidentificationofall

aetiologicalfactors,i.e.(i)thosefactorswhichpredisposetoplaquedepositionandretention,and

(ii)thosefactors,localorsystemic,whichinfluenceadverselythebehaviorofthetissue.Itshould

gowithoutsayingthatyoucannotremoveorcontrolfactors,whichhavenotbeenidentified,yet

alltoofrequentlytreatmentisreducedtothecontrolofsignsandsymptoms,andinevitably

diseaserecurs.

Atthetimeoftheinitialexaminationsomeattemptshouldbemadetoassessthepatient's

attitudetodentalhealth.Patientcooperationisessentialtothesuccessofperiodontaltreatment

anditisthisfactwhichmakesthetreatmentofperiodontaldiseasedifferentfromthatofcaries

andotherdentaldiseaseswhenthepatientcantakeamorepassiveattitude.

Patientexamination

Theexaminationshouldbemethodicalandcomprehensiveandshouldfollowthestandard

patternoftheclassiccasehistory.

Presentcomplaintanditshistory

Apatientwithperiodontaldiseasemayhavenocomplaintatallandtheobvioustothe

presenceofanydiseaseinthemouth;indeed,thepatientmaybesuspiciousofanysuggestionthat

diseaseispresent!Themostcommoncomplaintsarebleedinggums,looseteeth,driftingofthe

teeth(usuallytheupperincisors),nastytaste,halitosis,swellingofthegums,discomfortand

occasionallyacutepain.

Fewpatientsattheinitialconsulationprovideconciseandcompletelyrelevantinformation.

Alltoooften,thenecessaryinformationhastobeelicitedbyabstractionfromalong,sometimes

rambling,andaccountwhichmustbelistenedtowithpatienceandcloseattention.Inaddition,

Pertinentquestionsshouldbeasked:

Areyouinpain?

Whereisthepain?

Isitathrobbingordullpain?

Doesthepainkeepyouawake?

Whatbringsonthepain--hot,cold,sweet,biting?

Haveyouhadpaininthepastoristhisthefirsttime?

Whattreatmenthaveyoureceivedforpain?

Doyourgumseverbleed?

Whenyoubrushyourteeth?

Whenyoueathardfood?

Didyourgumsbleedinthepast?

Whattreatmentdidyoureceive?

Doanyofyourteethfeelloose?

Haveyoualwayshadthatspacebetweenyourfrontteeth?

Haveyouhadanyswellinginyourmouth?Where,when,etc.?

Dentalhistory

Doyougotothedentistregularly?

Whatwasthelasttreatmentyoureceived?

Whendidyoulasthaveascaling,i.e.Cleaningbyyourdentist?

Doyouhaveanydentures(falseteeththatyoucantakeout)--howlonghaveyouhad

them?

Haveyouanyfalseteeththatarefixedin--howlonghaveyouhadthem?

Atthisstagequestioningabouthomecarecanbeawasteoftime.

Answerstosuchquestionsas6Howoftendoyoucleanyourteeth?9,areoftensuspect,asthe

patientislikelytosaywhatheimaginesheissupposedtosay,i.e.twiceaday,nightandmorning.

Evenifthishappenstobethetruth,itgivesnoindicationofthequalityoftheperformance;only

anexaminationofthemouthprovidesinformationaboutthat.

Atthistime,someideaabouthabitsshouldbegleaned,e.g.smoking,clenching,andnight

grinding,andbitingpencilsandsoon.

Medicalhistory

Althoughamedicalhistorymaynotseemrelevanttosomepatients,itisessentialtoobtain

oneforanumberofreasons:

1.Thepatientmaybesufferingfromsomecondition,e.g.Cardiovasculardisease,renal

disease,etc.,whichwinrequirespecialprecautionsand/ormodificationofthetreatmentandwill

necessitatecommunicationwiththepatient5sphysician.

2.Systemicconditions,e.g.Pregnancy,diabetes,winalterthewayinwhichtheperiodontal

tissuesbehaveandmaydemandmedicalattentionbeforeperiodontaltreatmentcanbecarriedout.

3.Themouthmaybethesiteofsomemanifestationofasystemiccondition,e.g.Anaemia,

whichcouldaffectanyperiodontaltreatment.

4.Thepatientmaybereceivingmedication,e.G.Monoamineoxidaseinhibitorsfor

depression,whichmayconnectwithmedicationinvolvedintheperiodontaltreatment,e.g.

Generalanaesthetics.

Amedicalhistoryshouldrecordanypresentillnessandmedication;anypastseriousillness

andmedication,e.g.Steroidstakenintherecentpast,allergies,especiallyanyhistoryofpenicillin

sensitivity,abnormalbleedingtendencies,inparticularexcessivebleedingafterinjuryortooth

extraction.

Theuseofaquestionnairemaybehelpful.

Wheresomesystemicproblemexists,communicationwiththepatient'sphysicianis

essential.

Patientappraisal

Whiletakingthehistory,ageneralappraisalofthepatientshouldbemade,andsuch

featuresasobesity,generalposture,pallor,skinrash,heavybreathing,lippostureshouldbenoted.

Oralexamination

Theexaminationofthemouthshouldbecarriedoutinamethodicalandthoroughmanner;

thisisthedentist9sspecialarea.Halitosisisnoted,asthemouthisopenedorevenearlierwhen

thepatientisgivingahistory.

1.Theoralmucosa,cheeks,lips,tongue,palate,floorof'mouthandvestibules,are

examinedforulceration,vesicles,swelling,erodedpatches,abnormalcolourandwhitelinesor

patches.

Toothindentationsinthemarginofthetongueandinterdentalkeratosis,i.e.Awhitelinein

thecheekattheleveloftheocclusion,oftenindicatesaclenchingorgrindinghabit.

Aphthousulcersfrequentlyoccurinthelabialorlingualvestibuleorinsidethelips.Lichen

planusmaybeseenasfine,interlacingwhitelinesonthecheeksoralveolarmucosa.Vesiclesor

erodedpatchesshouldbefullyinvestigated.

Asinusonthealveolarmucosawithorwithoutthedischargeofpusonpressure,indicates

thepresenceofanalveolarabscess.

Intheolderindividual,asquamous-cellcarcinomamayappearasapainlessswelling,ulcer

orerodedwhitepatchinanypartoftheoralmucosa,butespeciallyinthevestibules.Orallesions

ofprimary,secondaryortertiarysyphilismayappearonthelips,tongue,palateandeventhe

gingivae;widespreadcandidalesionsinayoungmalecouldbeindicativeofHIVinfection.

Anydeparturefromthenormmustbeexaminedcarefully,andifinfectionormalignant

diseaseissuspected,anexaminationofthesubmandibularandcervicallymphnodeswillhelp

withadiagnosis.Immediatereferraltothephysicianorappropriatespecialistisessential.

2.Removableappliances,ifpresent,shouldbeexaminedfortheirfit,designand

relationshiptoanyinflammationoftheoralmucosaandgingiva.

3.Oralhygiene.Notepresenceandpositionofplaque,supragingivalandsubgingival

calcalus.SubginigivalcalculuscanbedetectedwithasharpprobeoraCrosscalculusprobebut

mayalsobeseenasadarkblueshadowinthegingivalmargin.Theuseofadisclosingagentwill

helptoidentifyplaqueanddemonstrateitspresencetothepatient.Sometimesthelocationof

plaqueandcalculuspointstoapredisposingfactor,e.G.Betteroralhygieneontheleftsideis

usuallyassociatedwithright-handedtoothbrushing;interproximaldepositsandgingival

inflammationmaybecausedbytheoverhangingmarginsofrestorationsorpoorcontactrelations.

4.Teetharechartedandcavities,restorationsandmalalignmentsrecorded.Attritionmay

indicateagrindinghabit;abrasionavigorousanddamagingtoothbrushingtechnique.

5.Gingivaeareexaminedforcolour,shape,sizeandconsistency,keepinginmindthe

pictureofhealth,pink,knife-edged,streamlinedandfirm,anydeparturefromwhichcould

indicatepathology.

6.Pocketmeasurementshouldbecarriedoutoneachtoothandrecorded.Ideally,true

mesial,distal,facialandlingualmeasurementsarerequired,butthisispossibleonlywhereteeth

aremissing,sothatunimpededaccesstothesesurfacesispossible.Whereproximalteethare

present,measurementismadeatthelineangles,andonfacialandlingualsurfaces.Takingsix

readingsoneachtoothisidealbutmaybeverytimeconsuming,andifdiagnosisismadeata

reasonablyearlystageinperiodontalbreakdown,onlyoneortwomeasurementsmadeatthe

mesiobuccalandmesiolinguallineanglesmaybesufficient.Wherethereappearstobefurcation

involvementofmolars,ordriftingofincisors,facialandlingualmeasurementsontheseteethare

essential.

Apocket-measuringprobemustbefineenoughtoenteranarrowpocket,butmusthavea

bluntendsothatthetissueisnotperforated.Thesharp-endedprobeusedforthedetectionof

cariesshouldnotbeused.Thepocket-measuringprobemustbeinsertedintothepocket,asnear

paralleltotheaxisofthetoothaspossible;ifinsertedobliquely,afalsereadingwillbeobtained.

Greatcarehastobetakentomanipulatetheprobesothatthetruedepthofthepocketis

recorded.Delicatehandlingoftheprobemastisemployedtonegotiatesubgingivaldeposits

withoutimpactingagainsttherootsurface.Vigorousprobingisnotonlypainfulbutalsolikelyto

giveaninaccuratereading;evengentleprobingofinflamedgingivaecanbepainful.Theproblems

ofpocketmeasurementcanbedemonstratedbythefactthatpocketmeasurementafterlocal

anaesthesiausuallygivesgreaterreadingsthanintheunanaesthetizedtissue.

Gutta-perchaorsilverpoints,whichmaybecalibrated,maybeleftinsituduring

radiographicexaminationofsuspectedinfrabonypockets.

Inadditiontorecordingpocketdepth,itisimportanttoassesstheclinicalattachmentlevel

(amelocementaljunction,CEJ).Wherethereisconsiderablegingivalhyperplasiapocketingmay

befairlydeep;say5-7mm,bu