Calibration of clinical periodontal charting

The goal of clinical periodontal charting is to record gingival recessions, probing depths, and attachments levels at six sites per tooth or implant in mm. For all the measurements it appears to be reasonable to round up all the readings measured with the periodontal probe.

1. Gingival margin, probing depth, and attachment level

At every site, the value for "Gingival Margin" will be determined first followed by the measurement of the periodontal "Probing Depth". The value of "Attachment Level" will be calculated by the online pariodontal charting tool and displayed with a blue line in the diagram.

The "Gingival Margin" as the first value is the distance from the clinical gingival margin to any given reference such as, in most cases, the cemento-enamel junction. Crown margins and the margins of restoration should be chosen as a reference provided they are at least 3mm apical to the cemento-enamel junction (CEJ), otherwise, a virtual reference line should be chosen at the location of the original cemento-enamel junction.

The "Probing Depth" as the second value is the distance between the gingival margin and the bottom of the gingival sulcus or the periodontal pocket, respectively.

The "Attachment Level" for each site will be calculated based on the following formula:

Probing Depth (mm) – Gingival Margin (mm) = Attachment Level (mm)

Healthy periodontium

In a healthy periodontium, the cemento-enamel junction is located below the gingival margin and immediately above the attachment level. There is no attachment loss at sites with a healthy periodontium.

In this case, both values for gingival margin 1 and probing depth 2 are identical.

In the figure above, the attachment level is calculated as follows:

Attachment Level 0mm = Probing Depth 2mm – Gingival Margin 2mm

Healthy periimplant tissues

At healthy periimplant sites, the margin of the suprastructure is located somewhat below the margin of the periimplant mucosa. There is no alveolar bone loss at healthy periimplant sites.

In the figure above, the alveolar bone (attachment) level is calculated as follows:

Alveolar Bone (Attachment) Level 2mm = Probing Depth 3mm – Mucosal Margin 1mm

Gingival hyperplasia (overgrowth)

In some cases, the cemento-enamel junction may be located far below the gingival margin, however still immediately above the attachment level. This occurs in cases of gingival overgrowth or gingival hyperplasia.

In this case, again, both values for gingival margin 1 and probing depth 2 are identical.

In the figure above, the attachment level is calculated as follows:

Attachment Level 0mm = Probing depth 5mm – Gingival Margin 5mm

Note: Pseudo pockets are pockets of 4mm and more without attachment loss.

Healthy periimplant tissues in the esthetic zone

At healthy periimplant sites in the esthetic zone, the margin of the suprastructure is located further below the margin of the periimplant mucosa. There is no alveolar bone loss at healthy periimplant sites in the esthetic zone.

In the figure above, the alveolar bone (attachment) level is calculated as follows:

Alveolar Bone (Attachment) Level 2mm = Probing Depth 5mm – Mucosal Margin 3mm

Periodontal pocket

At some diseased sites, the cemento-enamel junction may be located somewhat below or above the gingival margin. The distance between the gingival margin and the bottom of the periodontal pocket is then recorded as the periodontal probing depth 2.

In the figure above, the attachment level is calculated as follows:

Attachment Level 5mm = Probing Depth 7mm – Gingival Margin 2mm

Note: Periodontal pockets of > 4mm following active periodontal thrapy are so called, residual pockets.

Periimplant pocket

At sites with periimplantitis, the margin of the suprastructure may be located somewhat below or above the margin of the periimplant mucosa. The distance between the mucosal margin and the bottom of the periimplant pocket is then recorded as the periimplant probing depth 2.

In the figure above, the alveolar bone (attachment) level is calculated as follows:

Alveolar Bone (Attachment) Level 6mm = Probing Depth 7mm – Mucosal Margin 1mm

Gingival recession

Gingival recession is the condition seen when the gingival margin is located apically to the cemento-enamel junction. The value noted as the gingival margin 1 should be recorded as a negative value.

In the figure above, the attachment level is calculated as follows:

Attachment Level 6mm = Probing Depth 2mm – Gingival Margin -4mm

Periimplant recession

Periimplant recession is the condition seen when the mucosal margin is located apically to the margin of the suprastructure. The value noted as the mucosal margin 1 should be recorded as a negative value.

In the figure above, the alveolar bone (attachment) level is calculated as follows:

Alveolar Bone (Attachment) Level 4mm = Probing Depth 2mm – Mucosal Margin -2mm

Six sites per tooth or implant

The selection of the six sites per tooth or implant for the measurement of both periodontal pockets and attachment levels is critical. Each tooth or implant is divided into six sections when observed from the occlusal aspect. The site with the deepest periodontal or periimplant probing depth should be recorded for each section.

Angulation of the periodontal probe

The periodontal probe is inserted along the root surface of the tooth in order to measure the periodontal probing depths. The instrument should be angulated in a mesio-distaler direction A or B, respectively while keeping it parallel to the long axis of the tooth (avoid angulations in a buccal-lingual direction).

2. Severity of furcation involvement

Furkations of all molars and first premolars of the upper jaw should be assessed with a furcation probe. The horizontal component of probing is graded (0 - 3) according to the following criteria (Hamp et al., 1975):

Grade 0 = Furcation not detectable

Grade 1 = Furcation detectable, with a horizontal component of probing ≤3mm

Grade 2 = Furcation detectable, with a horizontal component of probing >3mm

Grade 3 = Furcation is opened through and through

3. Tooth mobility

Tooth mobility should be determined using two single-ended instruments and assessed according to the following criteria (Miller, 1950):

Grade 0 = Normal (physiologic) tooth mobility

Grade 1 = detectable mobility (up to 1mm horizontally)

Grade 2 = detectable mobility (more than 1mm horizontally)

Grade 3 = detectable vertical tooth mobility

Literature

Miller S. C., Textbook of Periodontia, 3rd edition, The Blakiston Co., Philadelphia and Toronto, 1950.

Hamp S. E., Nyman S., Lindhe J., Periodontal treatment of multirooted teeth. Results after 5 years. J. Clin. Periodontol. 1975;2:126–135. doi: 10.1111/j.1600-051X.1975.tb01734.x.