CAL and PSR
CAL and PSR
CAL and PSR
MODULE OUTLINE
SECTION 1
443
SECTION 2
446
SECTION 3
451
SECTION 4
455
441
SECTION 5
PSR Examination
Periodontal Screening and Recording System Documenting PSR Codes
461
SECTION 6
Skill Application
Practical Focus Skill Evaluation Module 21: Advanced Probing Techniques
465
KEY TERMS
Periodontal attachment system Junctional epithelium Fibers of the gingiva Periodontal ligament bers Alveolar bone Loss of attachment Periodontal assessment Furcation area Mobility Horizontal tooth mobility Vertical tooth mobility Mobility-rating scales Edema Gingival recession Clinical attachment level Clinical attachment loss Attached gingiva Width of attached gingiva Furcation Bifurcation Trifurcation Furcation area Furcation involvement Furcation probe Periodontal Screening and Recording System World Health Organization probe Color-coded reference marking
LEARNING OBJECTIVES
1. Discuss the uses of calibrated and furcation probes in performing a periodontal assessment. 2. Describe the rationale for assessing tooth mobility. 3. Demonstrate the technique for assessing tooth mobility, and use a mobility rating scale to classify the extent of mobility. 4. Describe the rationale and technique for determining the level of the gingival margin. 5. Describe the consequences of loss of attachment to the tooth. 6. Given the probing depth measurements and gingival margin levels for a tooth, compute the clinical attachment loss. 7. Describe the rationale for furcation detection. 8. Demonstrate correct technique for use of a furcation probe on a periodontal typodont, and classify furcation involvement according to severity. 9. Use advanced probing techniques to accurately assess a student partners periodontium. 10. Describe the rationale for the PSR examination and the treatment implications for each of the PSR Codes. 11. Use an appropriate probe to complete a PSR examination of two sextants on a student partner and record these ndings using the correct PSR Code. 12. For simulated patient cases, use periodontal measurements to differentiate a healthy periodontium from periodontitis, and record these ndings on a periodontal chart.
442
443
SECTION 1
Junctional epithelium
Alveolar bone
Cross Section of the Periodontal Attachment System. A, The periodontal attachment system in health. B, Destruction of the periodontal attachment system in disease.
444
Gingival margin
Crest of bone
Bone Support in Health. In health, most of the tooth root is surrounded in bone. The crest of the alveolar bone is located very close to the crowns, only 1 to 2 mm apical to (below) the cemento-enamel junctions of the teeth.
Gingival margin
Crest of bone
Bone Support in Gingivitis. In gingival disease, there is no loss of alveolar bone and the crest of the alveolar bone remains only 1 to 2 mm apical to (below) the cemento-enamel junctions of the teeth.
Gingival margin
Crest of bone
Bone Loss and Pocket Formation in Periodontitis. In periodontitis, bone is destroyed and the teeth are not well supported in the arch. In this example of bone loss, the gingival margin has remained near the cemento-enamel junction, creating deep periodontal pockets.
445
Gingival margin
Crest of bone
Loss of Bone and Gingival Recession in Periodontitis. In this example of periodontitis, the gingival margin has receded, and the tooth roots are visible in the mouth. Note that the alveolar bone is at the same level in this example and the one beforeonly the level of the gingival margin differs in these two examples.
TABLE 21-1.
Attachment in Health
Junctional epithelium attaches to enamel at base of sulcus Fibers brace the tissue against the crown Many bers attach root to bone of socket Most of the root is surrounded by bone; the tooth is rmly held in its socket
446
SECTION 2
ORAL DEVIATIONS
A calibrated probe is used to determine the size of an intraoral lesion or deviation. The nding of an oral lesion in a patients mouth should be recorded in the patients chart. Information recorded should include the (1) date, (2) size, (3) location, (4) color, and (5) character of the lesion as well as (6) any information provided by the patient (e.g., duration, sensation, or oral habits). For example: January 12, 2004: a soft, red papillary lesion located on the buccal mucosa opposite the maxillary left rst premolar; measuring 5 mm in an anterior-posterior direction and 6 mm in a superiorinferior direction.
Documenting Measurements. It is best to use anatomic references rather than length or width to document your measurements on the chart (e.g., as the anterior-posterior measurement and the superior-inferior measurement).
Determining the Height of a Raised Lesion. Place the probe tip on normal tissue alongside of the deviation. Imagine a line at the highest part of the deviation, and record this measurement as the height.
Determining the Depth of a Sunken Lesion. Carefully place the probe tip in the deepest part. Imagine a line running from edge to edge of the deviation. The depth is the distance from this imaginary line to the base of the deviation.
447
TOOTH MOBILITY
Mobility is the loosening of a tooth in its socket. Mobility may result from loss of bone support to the tooth. Most periodontal charts include boxes for documenting tooth mobility. 1. Horizontal tooth mobility is the ability to move the tooth in a facial-lingual direction in its socket. Horizontal tooth mobility is assessed by putting the handles of two dental instruments on either side of the tooth and applying alternating moderate pressure in the facial-lingual direction against the toothrst with one, then with the other instrument handle. 2. Vertical tooth mobility, the ability to depress the tooth in its socket, is assessed using the end of an instrument handle to exert pressure against the occlusal or incisal surface of the tooth. 3. There are many mobility-rating scales for recording tooth mobility on a periodontal chart. One useful rating scale is indicated in Table 21-2.
Assessing Horizontal Tooth Mobility. Using the ends of two handles, apply alternating pressure, rst from the facial and then from the lingual aspects of the tooth.
Assessing Vertical Tooth Mobility. Use the end of an instrument handle to exert pressure against the occlusal surface or incisal edge of the tooth.
TABLE 21-2.
Mobility Scale
Classication
Class 1 Class 2 Class 3
Description
Slight mobility, up to 1 mm of horizontal displacement in a facial-lingual direction Moderate mobility, greater than 1 mm of horizontal displacement in a facial-lingual direction Severe mobility, greater than 1 mm of displacement in a facial-lingual direction combined with vertical displacement (tooth depressible in the socket)
448
Gingival Margin at the Cemento-Enamel Junction (CEJ). The gingival margin is at the CEJ in this photograph.
Gingival Margin Signicantly Covers the Cemento-Enamel Junction (CEJ). The gingival margin is signicantly coronal to the CEJ in this photograph.
449
B Gingival Margin Signicantly Apical to the Cemento-Enamel Junction. Known as recession, this relationship leads to exposure of the root surface. A, Gingival recession on the facial aspect of three teeth. B, Area of gingival recession on the lingual aspect of a mandibular incisor.
450
24
23
22
21
20
19
18
17
L
Facial
451
SECTION 3
452
Calculating CAL in the Presence of Gingival Recession. When recession is present, the CAL is calculated by ADDING the probing depth to the gingival margin level. For example: Probing depth measurement: Gingival margin level: Clinical attachment loss:
4 mm 2 mm 6 mm
Calculating CAL When the Gingival Margin Covers the CEJ. When the gingival margin is coronal to the CEJ, the CAL is calculated by SUBTRACTING the gingival margin level from the probing depth. For example: Probing depth measurement: Gingival margin level: Clinical attachment loss:
9 mm 3 mm 6 mm
453
Calculating CAL When the Gingival Margin is at the CEJ. When the gingival margin is at the CEJ, no calculations are needed because the probing depth and the clinical attachment level are equal. For example: Probing depth measurement: Gingival margin level: Clinical attachment loss:
6 mm 0 mm 6 mm
R
Facial
32
31
30
29
28
27
26
25
454
BOX 21-3
Formula: Calculate the width of the attached gingiva by subtracting the probing depth from the total width of the gingiva.
STEP 1: Measure the total width of the gingiva from the gingival margin to the mucogingival junction. STEP 2: Measure the probing depth (from the gingival margin to the base of the pocket). STEP 3: Calculate the width of the attached gingiva by subtracting the probing depth from the total width
of the gingiva.
455
SECTION 4
Clinically Visible Furcation. The furcation of this mandibular rst molar is visible in the mouth because of bone loss and tissue recession.
Radiographic Evidence of Furcation Involvement. A, This radiograph shows furcation involvement on the mandibular rst molar. B, This radiograph shows furcation involvement on a maxillary rst molar. (Courtesy of Dr. Robert P. Langlais.)
456
Mandibular molars usually are bifurcated with mesial and distal roots.
Facial
Lingual
Maxillary rst premolars can be bifurcated with buccal and palatal roots. When bifurcated, the roots of a maxillary rst premolar separate many millimeters apical to the cemento-enamel junction.
Mesial
Distal
Lingual root
Mesiobuccal root
Distobuccal root
Maxillary molar teeth usually are trifurcated with mesiobuccal, distobuccal, and palatal (lingual) roots.
Facial furcation
Facial
Mesiobuccal root Lingual root
Lingual
On the mesial surface of a maxillary molar, the furcation is located more toward the lingual surface. On the distal surface of a maxillary molar, the furcation is located near the center of the tooth.
Mesial furcation
Distal furcation
Mesial
Distal
457
Furcation Probes. Probe A has black bands from 3 to 6 mm and from 9 to 12 mm. Furcation probes with millimeter markings often are used in research studies. Other furcation probes, such as probe B, do not have millimeter markings.
3 6 9 12
WORKING-END SELECTION
The correct working-end of the probe has been selected if the lower (terminal) shank is positioned parallel to the tooth surface being examined. The incorrect working-end has been selected if the lower shank is perpendicular to the long axis of the tooth surface being examined.
Working-End Selection for Furcation Probe. A, The correct end of a furcation probe has been selected if the lower shank is positioned parallel to the long axis of the tooth surface being examined. B, The incorrect working-end has been selected if the lower shank is perpendicular to the tooth surface being examined.
458
Class
I
Symbol
JE
Bone level
II
The probe is able to partially enter the furcationextending approximately one third of the width of the tooth but it is not able to pass completely through the furcation.
JE Bone level
Facial view
III
In mandibular molars, the probe passes completely through the furcation between the mesial and distal roots. In maxillary molars, the probe passes between the mesiobuccal and distobuccal roots and touches the palatal root.
Bone level
Facial view
IV
Same as a class III furcation involvement except that the entrance to the furcation is visible clinically owing to tissue recession.
JE
Bone level
Facial view
459
R
Lingual
Facial 1
Directions
1. Use a periodontal typodont or mount an acrylic mandibular molar, maxillary rst premolar, and maxillary rst molar in modeling clay or plaster. Mount the teeth so that the furcation areas are exposed. 2. Position the probe at the gingival line at a location near where the furcation is suspected. 3. Direct the probe beneath the gingival margin. At the base of the pocket, rotate the probe tip toward the tooth to t the tip into the entrance of the furcation.
JE Bone level
Facial view
Mandibular Molars. The facial furcation is accessed from the facial. The lingual furcation is accessed from the lingual.
460
Bone level
Facial view
Maxillary First Premolar. The mesial furcation is accessed from the mesial. The distal furcation is accessed from the distal.
Facial view
Maxillary MolarsFacial Aspect. The facial furcation is accessed from the facial.
Lingual aspect
Lingual view
Maxillary MolarsLingual Aspect. The mesial furcation is accessed from the lingual. The distal furcation is accessed from the lingual.
461
SECTION 5
PSR Examination
PERIODONTAL SCREENING AND RECORDING SYSTEM
The American Dental Association and the American Academy of Periodontology suggest that all routine dental examinations include a screening examination using the Periodontal Screening and Recording (PSR) System. A PSR examination can help to identify patients who need a comprehensive periodontal assessment. The results of this screening examination are used to separate patients into two broad categories: (a) those who have periodontal health or gingivitis and (b) those who have periodontitis. The unique aspects of the PSR system are the manner in which the probe is read and the minimal amount of information that is recorded. 1. A World Health Organization (WHO) probe is used for this examination. The WHO probe has a colored band (called the reference marking) located 3.5 to 5.5 mm from the probe tip. This color-coded reference marking is used when performing the PSR examination. 2. The mouth is divided into sextants for the PSR examination. Only one code is recorded for each sextant in the mouth. a. Instead of reading and recording six readings per tooth, the clinician needs to observe only the position of the color-coded reference marking in relation to the gingival margin and the presence of furcation invasion, mobility, mucogingival problems, or recession. b. Each sextant is assigned a single PSR code; the highest code obtained for the sextant is recorded. An X is recorded if a sextant is edentulous. c. The probe is walked circumferentially around each tooth in the sextant being examined. The color-coded reference mark is monitored continuously while probing. At each site probed, the color-coded reference mark is either (a) completely visible, (b) partially visible, or (c) not visible at all. 3. The PSR codes are recorded in a special PSR box chart.
The World Health Organization (WHO) Periodontal Probe. The probe has the following design features: (1) a 0.5-mm ball-tipped end and (b) a colored-coded reference mark located 3.5 to 5.5 mm from the explorer tip. Note that the other markings on the probe are not used when performing a PSR examination.
THE PSR EXAMINATION. For the PSR, the clinician needs to observe only the
position of the color-coded reference mark in relation to the gingival margin and the presence of furcation involvement, mobility, mucogingival problems, or gingival recession.
462
TABLE 21-4.
are present.
Gingival tissues are healthy with no bleeding
CODE 1:
Color-coded reference mark is completely visible
are present.
Bleeding IS present on probing.
CODE 2: Color-coded reference mark is completely visible in the deepest sulcus or pocket of the sextant.
Supragingival or subgingival calculus and/or
CODE 3: Color-coded reference mark is partially visible in the deepest sulcus or pocket in the sextant.
This code indicates a probing depth between 3.5
463
TABLE 21-4.
CODE *: The * symbol is added to the code of a sextant exhibiting any of the following abnormalities: furcation involvement, mobility, mucogingival problems, or recession extending into the colored area of the probe. Pictured here is an example of a sextant that has teeth with furcation involvement; therefore, the symbol should be recorded next to the sextant code.
CODE * Example: Recession This sextant exhibits gingival recession and mucogingival problems and therefore should include the * symbol next to the sextant code.
CODE * Example: Mucogingival Problems This sextant exhibits mucogingival problems and calculus and therefore should include the * symbol next to the sextant code.
464
* symbol to indicate one of the following problems: furcation involvement, mobility, mucogingival problems, or recession extending into the colored area of the probe.
Month
Day
Year
TABLE 21-5.
Code
Code 0, 1, or 2 in all sextants Code 3 in one sextant Code 3 in two or more sextants Code 4 in one or more sextants
465
SECTION 6
Skill Application
PRACTICAL FOCUS
466
24
23
22
21
20
19
18
17
L
Facial
467
468
10
11
12
13
14
15
16
L
Lingual
469
CRITERIA:
Position: Demonstrates correct principles of positioning for the clinician, patient, equipment, and area Dental Mirror: Uses the mirror correctly for retraction and/or indirect vision Infection Control and Communication: Maintains infection control throughout the assessment procedure Explains assessment procedure to the patient Intraoral Fulcrum and Grasp: Fulcrums on same arch, near tooth being instrumented Probing Technique: Positions probe parallel to the tooth surface Keeps tip in contact with the tooth surface and uses small walking strokes within the sulcus to cover the entire circumference of each tooth Tilts probe and extends tip beneath contact area to assess interproximal area Attached Gingiva: Measures the amount of attached gingiva on one tooth in each area
OPTIONAL GRADE PERCENTAGE CALCULATION
Area 1 Area 2 I I
Part 1: Total points (18 possible points) Part 2: Total points (24 possible points) Part 3: Total points (8 possible points) Calculate Total Ss for Parts 1, 2, and 3. Grand Total of Ss ________ divided by Total Points Possible (50) equals the Percentage Grade ________
470
Student:
QUADRANT
1
ASPECT
Facial Lingual
TOOTH #
#
STUDENT READINGS
EVALUATOR READINGS
Facial Lingual
Facial Lingual
Facial Lingual
Total number of readings within 1 mm of evaluators measurement ______. (24 possible points) EVALUATORTransfer total number of points to page 1 of Assessment Evaluation Form.
Attachment Loss
Total number of S evaluations for technique with furcation probe ______. (5 possible points) Total number of correct CAL calculations ______. (3 possible points) EVALUATORTransfer total number of points to page 1 of the Assessment Evaluation Form.