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DIAGNOSTIC

INSTRUMENTS IN
PERIODONTICS

CONTENT
INTRODUCTION

PERIODONTAL PROBES
NON PERIODONTAL PROBES
RADIOGRAPHIC ASSESSMENT

Definition : Diagnosis is defined as identifying the

disease from an evaluation of history, signs and


symptoms, laboratory tests and procedures.
Importance :
a. It identifies and indicates the nature of etiological
factors
b. Indicates the nature of pathological processes
c. It is essential for treatment planning
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Diagnosis Involves
Analysis of case history
Evaluation of clinical signs and symptoms
Results of tests (Probing, Mobility, Radiograph, blood

test etc.)

Diagnosis Determines
Presence of disease
Type of disease
Underlying disease process
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A Diagnostic refers to tools, procedures or

technologies that are used in determination of


diagnosis
used to:

a) predisposing risk factors


b) identify early disease
c) specific type of disease
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PERIODONTAL PROBES
Orban as the eye of the operator beneath the gingival margin
Latin word Probo, which means to test.
Gold standard
Simonton (1925) and Box (1928) were among the first to advocate

the routine use of calibrated probes


locate calculus, measure gingival recession, width of attached gingiva and

size of intraoral lesions, identify tooth and soft-tissue anomalies, locate


and measure furcation involvements and determine mucogingival
relationships and bleeding tendencies.
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Most widely used


Clinical assessment of connective tissue destruction in

periodontitis
Gold standard recording changes in periodontal status
Probing depth is measured from the free gingival margin
(FGM) to the depth of the probable crevice.
not the most objective measure of loss of periodontal tissues

Pihlstrom (1992) classified probes into three

generations.

In 2000, Watts extended this classification by

adding fourth- and fifth-generation probes.

GENERATIONS OF PERIODONTAL PROBES


FIRST GENERATION
(CONVENTIONAL)
PROBES

Conventional manual probes that do not


control probing force or pressure and
that are not suited for automatic data
collection.
The design of probes are either tapered, round, flat, or
rectangular with smooth rounded ends and are calibrated
in millimeters at various intervals.
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Examples of 1st generation probes


1.Mrquis color coded probe
2.Williams probe
3.UNC-15 probe
4.University of michigen o probe
5.WHO probe
6.Nabers probe
7.Goldman fox probe
8.Novatech probe(UNC-12 probe)
9.Plastic probe(Dental implants)
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Marquis color coded probe


Caliberations present at 3,6,9,12 mm
Easy to read
Thin shank allows access into

tight, fibrotic sulci


Disadvantage-Markings must be
estimated between color bands
Thin tip may penetrate junctional
epithelium

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UNC-15 probe
Color-coded at 5,10 and 15 no. marking
Thin shank allows access into

tight fibrotic sulci


UNC 15 is mainly for clients
with attachment loss

Tip design: thin tip

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Williams probe
Invented in 1936, 1943 by periodontist Charles

H.M. Williams, the Williams' periodontal probe is


the prototype or benchmark for all first-generation
probes
These probes have a thin stainless steel tip of 13 mm

in length and a blunt tip end with a diameter of 1 mm.


The probe tips and handles are enclosed at 130o.
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circumferential lines at 1 mm, 2 mm, 3 mm, 5 mm, 7

mm, 8 mm, 9 mm, and 10 mm.

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University of michigen o probe


Without williams
marking

Caliberations present at 3-6-8 mm


Round, fine tapered, narrow

diameter

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With williams
marking

Caliberations present at 1 mm, 2 mm, 3 mm, 5 mm, 7

mm, 8 mm, 9 mm, and 10 mm.


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WHO probe /CPITN probe


Also called as CPITN probe
The Community Periodontal Index of Treatment

Need (CPITN) probe was designed by Professors


George S. Beagrie and Jukka Ainamo in 1978
CPITN probes are recommended for use when
screening and monitoring patients with the CPITN
index

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The index and its probes were first described in

World Health Organization's (WHO) Epidemiology,


etiology, and prevention of periodontal diseases.
The probe was designed for two purposes

1.Measurement of pocket depth


2. detection of subgingival sulcus

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The FDI World Dental Federation/WHO Joint

Working Group 1 has advised the manufacturers of


CPITN probes to identify the instruments as
1.CPITNE (epidemiologic), which have 3.5-mm
and 5.5-mm markings,

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2.CPITNC (clinical), which have 3.5-mm, 5.5-mm,

8.5-mm, and 11.5-mm markings


CPITN-C probe have thin handles

and are lightweight (5 gm).


The probes have a ball tip of 0.5 mm
with a black band between 3.5 mm
5.5 mm, as well as black rings at
8.5 mm and 11.5 mm

,
and

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16 mm long
Tip and shank -90degree

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Nabers probe
Curved, and it is used for measuring into the furcation

area between the roots of a tooth.


Used to detect and measure the involvement of furcal

areas by the periodontal disease process in multi rooted


teeth.

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Used in the assessment of more complex clinical cases,

including those with a restorative treatment.


probes can be color-coded or without demarcation
Shank : Round tapered and curved
Measurement : Calibrated and non calibrated
Tip design : Blunted tip

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Plastic probes
SHANK: Thin, round and tapered.

MEASUREMENT:

Color-coded

and

variable

measurement depending on manufacturer.


TIP DESIGN: Thin tip or ball tip.

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ADVANTAGES: Ball tip for patient comfort and less

chance of penetration.
Color-coded, easy to read markings.
Thin shank allows access into tight fibrotic sulci.
Will not scratch implants.
DISADVATAGES: When markings wear away, entire

probe or probe tip unscrewed and disposed off


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Markings Color coded at 3,6,9 and 12-2N MESIAL

AND DISTAL FURACTION


ADVANTAGES : Ideal for detection of mesial and

distal Furcations in maxillary molars


D/A : May feel bulky when clinician is accustomed to

using a periodontal explorer for furcation detection


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Goldman Fox probe


Shank: flat
Measurement ; 1,2,3,5,7,8,9,10 mm
Tip design :blunt or wide
Advantages : no mark at 4 and 6 mm
Disadvantages: flat shank does not allow access

into tight fibrotic pockets


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Novatech probe(UNC-12)
Shank : upward and right angled bend
Measurement: availability in variety of designs
Tip: many designs
Advantages : posterior areas easy access

Disadvantages : bulky due to angulation


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2nd generation of
periodontal probes

Developed in an effort to standardize and quantify

the pressure used during probing


Weinberg et al. stated that controlled force of 20 to
25 grams probes reduced examiner error and made
depth changes of less than 2mm clinically
meaningful.
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The second generation probes did not have

electronic data collection.


The technology of second generation probes was the
basis of the third generation probes, which included
the electronic data collection capability.

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Pressure sensitive , not exceed 0.2 N/mm2

(Waerhaug, 1952)
True Pressure Sensitive (TPS) probe:
Prototype , Hunter 1994
Disposable probing head
20 gm & 0.5mm dia

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First true pressure-sensitive periodontal

probe :
Gabathuler and Hassell (1971)
periodontal probe & a small piezoelectric pressure

sensor which was attached to the non-probing end of


the probe tip.

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In 1977, Armitage : Simple pressure-sensitive

periodontal probe holder :


To standardize the insertion pressure.

In 1978, van der Velden presented the "Pressure

Probe", which allowed probing force to be adjusted.


Cylinder & a Piston connected to a variable air pressure

system
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The electronic pressure-sensitive probe,

allowing for control of insertion pressure, was


introduced by Polson in 1980.
Polsons original design was modified: the probe is

known as the Yeaple probe, which is used in


studies of dentinal hypersensitivity (Kleinberg et
al., 1994).
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A simple, constant-force, periodontal probe

was presented by Borsboom and co-workers


(1981). Their instrument used a stainless steel
spring to generate constant force
Kalkwarf et al 1986:
force upto 30 g Junctional epithelium

50 g periodontal osseous defects

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3rd generation
probes

Controlled force application, automated measurement

and computerized data capture and storage


Foster-Miller probe (Foster-Miller Inc, Waltham,

MA): prototype.
Jeffcoat et al. in 1986
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capable of automated cemento-enamel junction

(CEJ) detection and direct measurement of


attachment level with a high level of repeatability
and accuracy.

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National Institute for Dental and Craniofacial Research (NIDCR)

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Gibbs et al. (1988) developed the Florida

Probe system (Florida Probe Corp, Gainesville,


FL):
constant probing force, precise electronic

measurement to 0.1 mm and computer storage of the


data and sterilization of all system parts entering or
close to the mouth
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CAL- Fixed reference point

occlusal surface of teeth- disk probe


prefabricated stent- Stent probe

Florida PASHA Probe- Modified sleeve, tip edge

0.125 mm

catch of the CEJ

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Birek et al. (1981) and McCulloch et al. (1981)

developed the Toronto Automated probe:


It used the occlusal/ incisal surface to measure

relative clinical attachment levels.


Goodson and Kondon (1988) used fiber optic

technology in their controlled-force Accutek


probe.
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The InterProbe (The Dental Probe Inc, Glen

Allen, VA), also known as the Perio Probe, is a


third-generation probe with a flexible probe tip,
Jeffcoat 1991

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4th generation
probes

Three-dimensional (3D) probes. Currently

under development

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5th generation probe

3D and non-invasive: an ultrasound or other device

is added to a fourth-generation probe.


aim to identify the attachment level without

penetrating it

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The only fifth-generation probe available, the

Ultrasonographic (US) probe (Visual Programs,


Inc, 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.

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NON-PERIODONTAL PROBES
1.CALCULAS DETECTION
Based on measurements of resonance vibrations of

ultrasonic treatment or autofluorescence induced by


laser irritation.

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Recently, a novel calculus detection system

DetecTar (Ultradent, Salt Lake City, UT, USA)


employing spectro-optical technology has been
suggested as a potential aid in detecting subgingival
calculus

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2.PERIODONTAL DISEASE EVALUATION

SYSYTEM
The Diamond Probe/Perio 2000 System is a
dental device designed to detect sulphide
concentrations of various forms (S, HS, H 2S and
CH3SH) in gingival sulci

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The system combines a conventional Michigan O

style dental probe with a sulphide sensor, which


measures periodontal probing depth, bleeding on
probing and sulphide levels simultaneously

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3.GINGIVAL TEMPERATURE
Increased blood flow and a very high metabolic rate
Kung et al Sensitive diagnostic devices for

measuring early inflammatory changes in the


gingival tissues
PerioTemp probe(Abiodent)=sensitivity of 0.1oC

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2 light indicating diodes:


Red-emitting diode higher temp
Green-emitting diode lower temp

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4.TOOTH MOBILITY
Periotest Probe is a hand-held probe,
Mobility is recorded in Periotest units (PTU) from 0

to 50.

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The instrument (BioResearch, Milwaukee,

Wisconsin, USA) taps each tooth with an impeller 16


times and measures the time taken for the tooth to
return to its original position.

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5.PERIOSCAN(Kala .M & Vandana K.L 1997 ,

(Aparna .B & Vandana K.L 1998)


Perioscan / BANA Reagent test is a rapid, 5
min, chair side colorimetric test for
detection of BANA enzyme possessed by
P.gingivalis, T.denticola & T.forsythus
(produce halitosis).
BANA Reagent strips are provided in
bottles of 20 strips for testing of up to 2
sites (tongue & plaque) per strip.
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For Analysis, the pocket & tongue

samples are placed on the lower reagent


strip separately, folded & incubated for 15
min at 55-60C. The lower portion of the
test strip is then separated from upper
strip portion & discarded. The upper strip
portion is then interpreted as positive
when distinct patches of blue color appear
(somewhat larger & darker than weak +ve
reaction) on a red brown background
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Conclusions : The Perioscan / BANA


Reagent test can be used effectively for
quick detection of BANA positive
organisms which produce oral malodor.

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6TH PERIOCHECK(Sharath K.M & Vandana K.

L ,1999)
Periocheck (Pro-Dentec , USA) measures
presence of non-specific neutral protease
activity in GCF.
This Kit contains Plastic disposable test

Slides,GCF collection strips,test result


Color scale & Incubator.
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Principle of the test : Neutral proteolytic

activity is monitored with insoluble


Remazole brilliant blue collagen powder
by estimating the production of soluble
dye labeled fragments.
It has Accuracy with correlation
coefficient of 0.91; Specificity to Elastase,
Trypsin & Collagenase and Sensitivity of
0.06 U/ul for visual scoring method.
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6.TANITA Breath Alert + HALITOX

(Mathew J. & Vandana K.L ,2006)


Small hand-held breath checking device,
detects VSCs & hydrocarbons in mouth air.
HALITOX ,a quick, simple colorimetric test
detects VSCs & Polyamines.It contains
Halitox reagent which has chemical reagents
which react with anaerobic bacterial
products (toxins) to produce yellow colored
reaction products.
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Mild yellow color indicates moderate

toxin & Bright yellow color indicates high


toxin levels.
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RADIOGRAPHIC ASSESMENT

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DENTAL X-RAYS
X-rays are produced by boiling off electrons from a

filament (the cathode)and accelerating the el to the


target at the anode.
The accelerated x-rays are decelerated by the target
material, resulting in bremsstrahlung.

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DISCOVERY
Wilhelm Conrad Roentgen, Bavarian physicist,
discovered the x-ray on 1895.
In 1895, German dentist Otto Walkhoff made
the 1st dental radiograph.
In 1895, New York physician made the 1st dental
radiograph in the united states using the skull.

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X-rays in dentistry serves as the most important


diagnostic tool.
Radiograph in dentistry are divided into two:
1. Intraoral radiograph.
2. Extraoral radiograph.

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INTRAORAL X-RAYS
Bite-wing X-rays : Bite-wing X-rays are used to

detect decay between teeth and changes in bone


density caused by gum disease.
Periapical X-rays : Periapical X-rays are used to
detect any abnormalities of the root structure and
surrounding bone structure.
Occlusal X-rays show full tooth development and
placement

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Most common techniques used in IOPA is bisecting

angle technique
Other technique is paralleling technique
Angulation used in bisecting angle technique are-

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For bitewing x ray paralleing technique is used


Bitewing view is taken to visualize the crowns of the

posterior teeth and the height of the alveolar bone in


relation to the cementoenamel junctions, which are
the demarcation lines on the teeth which separate
tooth crown from tooth root

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EXTRAORAL X-RAYS
Panoramic X-ray
Tomograms
Cephalometric projections
Sialography

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Panormic radiograph(OPG)
Film size used are
30 cm 12 cm (12 5) and 30 cm x 15 cm (12

6). The smaller size film receives 8% less X-ray


dosage on it compared to the bigger size.
Opg provides details about both arches and
surroundig structure in one film

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ADVANCES IN RADIOGRAPHI C ASSESMENT


Digital radiography
Digital subtraction radiography
Computer-assisted densitometric image analysis

system (CADIA)
Tuned aperture computed tomography (TACT)
Computed tomography (CT)

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Cone-beam computed tomography (CBCT)


Local computed tomography (LCT)
Magnetic resonance imaging (MRI)
Nuclear medicine bone scans
Optical coherence tomography (OCT)
Ultrasound imaging

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Other advances
1. Advances in microbiological analysis
Bacterial culturing
Direct Microscopy-dark-field or phase-contrast microscopy
Immunodiagnostic methods
Enzymatic methods
Diagnostic analysis based on Molecular Biology techniques

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2. New innovations
Proteome analysis
Genetic analysis

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Conclusion
After all these years of intensive research, we still lack a

proven diagnostic test that has demonstrated high


predictive value for disease progression, has an impact on
disease incidence & prevalence, & is simple, safe & costeffective.
Future application of advanced diagnostic techniques will

be of value in documenting disease activity & treatment


options
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References
Newman MG, Takei HH, Klokkevold PR, Carranza

FA. 10th edition. Carranzas Clinical Periodontology.


Saunders Company 2006. 579-601.
Ramachandra SS, Mehta DS, Sandesh N, Baliga V,

Amarnath J. Periodontal Probing Systems: A Review of


Available Equipment. Dentistry India 2009; 3(3): 2-10.
Jeffcoat MK, Wang IC, Reddy MS. Radiographic

diagnosis in periodontics. Periodontol 2000 1995; 7: 54-68.


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Bostanci N, Heywood W, Mills K, Parkar M,

Nibali L, Donos N. Application of label-free


absolute quantitative proteomics in human gingival
crevicular fluid by LC/MS E (gingival exudatome). J
Proteome Res 2010; 9(5): 2191-2199

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Thank you

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