Periodontal Diagnosis —1977
Since these
A Status Report
by
WILLIAM C. HURT*
I N 1977 IT SEEMS especially appropriate that periodon­
tists would take stock of the art and science of peri­
odontal diagnosis as presently practiced. A l l who de­
liver health care are under increasing scrutiny from
government, insurance carriers, patients and fellow
practitioners. Perhaps more than at any other time, the
practicing dentist finds himself involved in litigation
wherein the burden is upon him to defend, not only his
therapeutic methods but also his diagnostic acumen.
That these realities come at a time when periodontists
are engaged in extensive reflection relative to what
constitutes acceptable management of periodontal dis­
ease only emphasizes that now may be an opportune
time to review our understanding of diagnostic meth­
ods.
The clinical management of any disease depends
upon how well the doctor collects his patient data.
Usually, this information is derived from a thorough
case history followed by a detailed clinical and radio­
graphic examination, laboratory studies and consulta­
tions. W h e n completed such provides the data-base
from which judgments relating to etiology, diagnosis
and therapy are formed.
T H E C A S E HISTORY
One of the most important parts of any medical or
dental examination is the case history. Its value in
arriving at a correct diagnosis is immeasurable and to
neglect the taking of a good history is to be deprived of
1-3
a basic diagnostic t o o l . It is interesting to note that
some conditions, e.g. primary herpetic gingivostomati­
tis, often may be diagnosed by means of history alone.
While it is unwise to arrive at a diagnosis utilizing only
the history, it is equally unwise to make a diagnosis
without one. Besides the advantages it provides in
determining a correct diagnosis, there are several spin­
off benefits derived from a good case history: (1) coex­
istent systemic disease may be revealed; (2) the attitude
of the patient may be discerned; (3) rapport with the
patient may be established; (4) a good history is impor­
tant from a medico-legal standpoint.
Ten years ago Morris called attention to a significant
philosophical transition in dentistry which was moving
from a technically oriented profession to one that is
4
patient centered. H e pointed out that because of ad­
vances in the medical sciences, persons with frank dis­
* Department of Periodontics, Baylor College of Dentistry, 800
Hall Street, Dallas, Texas 75226.
533
ease are living long, active and useful lives.
medical patients also become dental patients the dentist
must be extremely careful that the rendering of dental
care will not be detrimental to the systemic well being
of those he treats. Subsequently, in two separate stud­
ies by Brasher and Rees involving 1,035 adult patients,
it was shown that 4 3 % of patients who present for
periodontal therapy have systemic conditions that
would require some modification of the treatment plan.
Drug allergies, blood-vascular and cardiac problems
5,6
were the most common d i s o r d e r s .
Another aspect of systemic health of concern to the
periodontist is the relationship between certain sys­
temic conditions and periodontal breakdown. Most
periodontists acknowledge that some systemic diseases
modify the course of periodontitis and hence should be
controlled before extensive therapy. Paralleling this
goes the moral and sometimes legal responsibility to
diagnose systemic disease that is first manifested by
oral signs and symptoms. Furthermore, it is a mark of
the times that dentists have begun to assume an ever
increasing role in detecting the hypertensive patient
even though there are no overt oral signs of this condi­
7
tion.
There is a trend in medicine and dentistry alike to
record more comprehensive case histories. T o this end,
the multiple question forms, while helpful, are not
considered sufficient for the many parameters that
8
must be explored. There are overriding medical rea­
sons for this approach but an additional legal one may
be noted — such documentation may be decisive to the
defense in a malpractice suit.
Concerns such as these have resulted in the expanded
use of: (a) the medical history, (b) consultation with
physicians and (c) clinical laboratories.
PROBING
Periodontal probing is the time-honored method for
detecting the periodontal lesion. N o diagnostic method
is so closely identified with periodontal practice as
probing. Its effectiveness is such that there is little
likelihood that it will be displaced by any other proce­
dure in the forseeable future. While acknowledging the
usefulness of the periodontal probe it is also important
to recognize its limitations. T w o of the more important
limitations are: (1) it does not consistently appraise
inflammatory or destructive activity and (2) it does not
accurately locate the crestal bone height. Prichard has
stated that "the exact topography of the alveolar proc­
ess affected by periodontal disease can be determined
only by visual examination during surgical explora­
9
t i o n " . H e further explains that while careful periodon­
tal probing is essential in the periodontal examination
for determining pocket depth and width the procedure
does not verify the precise position of the bone.
There are a number of variables that affect probing
measurements. A m o n g these are diverse degrees of
probing skill observed among dentists. This is reflected

534 Hurt
in efforts to "standardize" participating examiners be­
fore initiating clinical studies requiring probe measure­
ments.
A n effort to ascertain the role pressure plays in
probing has been undertaken by Hassell and co-work­
10
ers. Using a pressure sensitive periodontal probe,
significant differences between probing force and de­
tected pocket depth were observed among six clini­
cians. However, in this study there was only a very
loose correlation (not significant statistically) that ex­
isted between force and depth scoring. It was noted that
deep pockets were generally probed with less force.
More important than the amount of pressure placed on
the probe was the probing technique. "Searching" ap­
pears much more critical than force. According to these
investigators heavy probing force is contraindicated
since it does not lead to greater precision.
In another experiment utilizing the same pressure
sensitive probe Gabathuler and Hassell noted consider­
able variability in probing force even during gentle
exploration of the gingival sulcus. They point out that
11
tooth form and position affect probing force.
12
Recent work by Sivertson and Burgett followed by
additional evidence by Listgarten and co-workers
demonstrates that during periodontal probing the point
of a fine probe often passes through the junctional
epithelium to the connective tissue. This was suggested
14
to be the case by Waerhaug in I 9 6 0 . In their study of
healing mucoperiosteal flaps Kohler and Ramfjord
demonstrated clinically and microscopically that the
15
probe penetrated to connective tissue. Such findings,
coupled with the known width of the junctional epithe­
16
lium (0.71-1.33 m m ) may require a reassessment of
the 2 to 3 mm physiologic crevice depth concept.
Several authors have advocated a "sounding" tech­
17,20
nique with the periodontal p r o b e . This is a method
for determining alveolar bone topography by passing
the point of the probe through anesthetized tissues.
The effectiveness of this diagnostic method for locating
bone position is well documented. The major disadvan­
tage is the requirement for local anesthesia.
In any discussion of probing it is well to again point
out the necessity of relating the gingival margin to the
cementoenamel junction. T o ascertain the depth of the
gingival crevice with a probe provides little information
relative to the amount of attachment that has been lost.
But to associate the crevice depth with the position of
the gingival margin, as it relates to the cementoenamel
junction, furnishes important data regarding the status
of the periodontal support. Oliver has emphasized that
while we do not, at present, know how to diagnose
active periodontitis, the pocket depth gives us informa­
tion about the history of the disease while the pocket
21
may be an etiologic factor. H e further states that
pocket depth per se does not indicate that periodontal
destruction is occurring, but for lack of a better method
we depend upon it to assess periodontal disease.
J. Periodontol.
September, 1977
LABORATORY STUDIES
While many physicians have long depended upon the
clinical laboratory for diagnostic data, dentists have not
22,23
found great use for clinical laboratory techniques.
Most of the laboratory tests utilized by dentists are for
preoperative information rather than for purposes of
diagnosis. There is some evidence that this is changing,
especially in the field of periodontics. This is because
there is an urgent need for a method to determine the
activity of gingival and periodontal disease. Recent
studies have emphasized that periodontal support can
be maintained in the face of certain deepened peri­
2 1 , 2 4 , 2 5
odontal s u l c i . Other deepened sulci are associ­
ated with varying degrees of periodontal breakdown. A
dilemma facing periodontists is how one determines
whether a deepened sulcus is active or quiescent.
One of the more promising approaches to laboratory
assessment of periodontal disease activity is a technique
26
introduced by Klinkhamer in 1963. This method pro­
vides for the calculation of the number of migrating
leukocytes in the oral cavity. Articles by Klinkhamer
and co-workers have shown a significant correlation
13
between the "orogranulocytic migratory rate" ( O M R )
27-31
and gingival h e a l t h . In 1972, Woolweaver, et al.
confirmed Klinkhamer's work in a study involving 50
32
individuals between the ages of 19 and 65 years. This
study showed that the O M R was independent of leuko­
cyte levels in the blood but that it correlated with the
severity of gingivitis. A n increase in gingivitis resulted
in an increase in the O M R . The report also showed that
there is a general increase in the O M R with increased
pocket depth. The authors speculated that the O M R -
pocket depth relationship may have been related to the
degree of gingival inflammation associated with the
33
pockets. In still another study D e G e a r e has demon­
strated the reproducibility of the O M R in healthy
mouths and as an index of periodontal health. A highly
positive correlation between the O M R and the Gingi­
3 4 ,3 5
val Index of Löe and Silness was found.
Recent developments in simplifying the determina­
tion of the O M R indicate that it can become either a
clinical laboratory procedure or an office procedure.
Since the accuracy of the O M R seems established in
ascertaining the degree of gingival inflammation, it
would not be surprising to find more periodontists
depending upon the test.
Another laboratory approach utilized in the diagno­
sis of gingivitis and early periodontitis was published in
1975. In this study the fucose content of blood plasma
and mixed saliva was determined in 44 patients. In
patients with periodontitis the fucose content of the
plasma was higher than in patients with gingivitis and
considerably higher than in the 20 control subjects. The
fucose content of saliva revealed a similar relation­
36
ship.
The Gingivitis Fluorescein Test was reported in
Volume 48
Number 9
37
1974. Capsules of sodium fluorescein were swallowed
by 27 subjects. The sodium fluorescein enters the saliva
via the crevicular fluid and can be detected photometri­
- 4
cally in dilution as high as 1 0 ppm. The amount of
fluorescein recovered with mouthwashing procedures
correlated highly with the clinical severity of gingivitis.
Another study comparing the Gingivitis Fluorescein
Test with the Sulcus Bleeding Index revealed that the
fluorescein test can only be utilized for evaluating indi­
vidual gingival inflammation in subjects with a Sulcus
38
Bleeding Index score higher than 2 .
Cytological examination of the gingiva has been sug­
gested as a possible diagnostic tool in determining the
presence and severity of gingival i n f l a m m a t i o n .
Stahl states that, within certain limits, oral cytology can
be used effectively to survey the character of gingival
margin epithelium. H e cautions, however, that in uti­
lizing cytology for diagnostic purposes our present
knowledge does not allow for determination of changes
other than gross variations. It is possible that with
refinements in cytological histochemistry, this type of
examination may evolve into a helpful diagnostic ap­
41
proach.
T H E CREVICULAR FLUID
Closely allied with laboratory studies is the subject of
crevicular fluid flow and its relationship to gingival
inflammation. In 1933 Boedecker suggested that the
42
crevicular fluid was an inflammatory exudate. While
this view has been generally accepted today, the clinical
significance of gingival crevice fluid flow is subject to
some disagreement. There has been controversy as to
whether measurement of the crevicular fluid flow is a
43-46
reliable, indication of gingival i n f l a m m a t i o n . One
report has shown that plaque products such as hyalu-
ronidase can increase crevicular flow without a change
47
in the inflammatory status of the gingiva. Another
study reported no direct relationship between the cre­
vicular fluid scores and gingival inflammatory infiltrate
44
assessed from biopsy material. Conversely, Oliver et
al. have stated that caution should be observed in
scoring gingival inflammation from biopsy specimens
since there are limitations in assessing the degree of
43
inflammation in microscopic specimens. Their find­
ings indicate that microscopic sections that do not uti­
lize special staining techniques often fail to reflect the
clinical inflammatory changes. These authors demon­
strated a close relationship between clinical Gingival
Index scores and the amount of gingival exudate. In
1970 Stallard, et a l . , concurred with the above finding
that the clinical inflammatory process demonstrated a
48
poor correlation with the microscopic picture.
There seems to be a general consensus that the flow
of crevicular fluid is sufficiently indicative of the gingi­
val inflammatory state that it can be used under clinical
49
conditions to monitor gingival inflammation. Recent
techniques have been developed to measure minute
Periodontal Diagnosis 535
volumes of fluid precisely and because of this, tests may
soon evolve that will enable the clinician to accurately
identify the quiescent lesion and the frankly destructive
lesion. Soon it may be possible for a clinician to identify
sub-clinical gingival inflammation by measuring crevic­
ular fluid flow and then analyze the fluid sample for
chemical or microbial constituents. ' In this way the49 50
activity or inactivity of the destructive process may be
ascertained. A n example of how this parameter is being
approached is in studies related to lactic dehydrogen­
ase. This enzyme, found in several body tissues is
released into the blood stream when there is acute
cellular destruction of any tissue or organ in which it is
39,40
found. It has been identified as a component of crevic­
51
ular f l u i d . A n attempt to relate total serum and gingi­
val exudate lactic dehydrogenase concentration to the
severity of gingivitis and periodontitis resulted in no
52
correlation discerned. While many such studies may
identify laboratory tests that are not helpful it seems
inevitable that some tests will prove valuable in deter­
mining periodontal disease activity.
There is a voluminous amount of literature pertain­
ing to the crevicular fluid. Most articles have been
included in an extensive review of the subject by Cima-
53
soni.
THE INDICES
In recent years numerous indices have been devel­
oped to assess gingival and periodontal disease. While
many of these are suited for epidemiological surveys
only, others have clinical application. H a z e n , Strat­ 54
55 56
f o r d and Margolis have recently reviewed the many
indices that have been proposed for the measurement
of gingival inflammation and periodontal disease.
The earliest index for gingival inflammation to
achieve wide acceptance was the P . M . A . index of
Schour and Massler. 5 7 ,5 8
This method quantitates the
degree of inflammation for the various divisions of the
gingiva, i.e., the papillary, marginal and attached gin­
giva. One of the more important aspects of this index is
that it allows for counting the number of gingival units
affected by disease.
54
According to H a z e n , the indices for gingival in­
flammation that presently seem the most helpful are:
(1) the Löe and Silness Gingival Index, (2) the Soumi 34
59
and Barbano index and (3) the Muhlemann approach
which includes a Sulcus Bleeding I n d e x . 60,61
The Löe and Silness Gingival Index utilizes six se­
lected teeth (3, 7, 12, 19, 23 and 28) and scores the
gingival inflammation about each. The buccal, lingual,
mesial and distal gingivae are each scored depending
upon the degree of inflammatory severity. The Gingi­
val Index for a given tooth is the average of the four
scores about that tooth. The Gingival Index for the
entire dentition is the average of the tooth Gingival
Indices. 62
The Soumi and Barbano index includes the examina­
tion of each papilla and margin from both the lingual

536 Hurt
and facial aspects. Scores from 0 to 2 are assigned each
unit depending upon the degree of inflammation. The
dental arches are divided into 12 segments and the
mean gingivitis score for each segment is obtained by
summing the unit scores within the segment and divid­
ing by the number of assessed units. 59
The Sulcus Bleeding Index has been introduced by
Muhlemann and c o - w o r k e r s . 60,61
In this index a diag­
nosis of gingivitis is made only if bleeding occurs upon
gentle probing of the sulcus. Gingival units that appear
clinically healthy are diagnosed as inflamed if bleeding
occurs when probed gently. Scores of 0 to 5 are given
depending upon the correlation of bleeding with
changes in color, swelling and degree of ulceration.
The Gingival Bleeding Index proposed by Carter and
Barnes also records the presence or absence of gingivi­
tis as determined by sulcular bleeding. In this index 63
unwaxed dental floss is passed interproximal^ into the
gingival sulcus on each side of the dental papilla and
moved up and down twice, taking care not to lacerate
the gingiva. While this index has not had extensive
clinical trial, it appears promising inasmuch as it is
simple to accomplish and can be used with individual
patients and i n groups of patients.
Indices helpful in determining periodontal bone loss
have been devised by various investigators. Perhaps
those most commonly used today are Russell's Peri­
odontal I n d e x , 64,65
Ramfjord's Periodontal Disease In­
dex 66, 6 7
and O'Leary's periodontal screening examina­
tion. 68
Russell's Periodontal Index is a method of scoring
periodontal disease based upon several signs of peri­
odontitis. Included in the scoring are: gingival inflam­
mation, pocket formation and loss of function. Each
tooth is scored and the values are totalled. This total is
divided by the number of teeth p r e s e n t .
Ramfjord's Periodontal Disease Index records gin­
givitis, periodontitis, plaque, calculus, mobility and oc­
clusion. It provides a survey of the total periodontal
state of the patient. The examination used in this index
involves the periodontal tissues about six selected teeth
(#3, 9, 12, 19, 25 and 28). According to Ramfjord
these six teeth supply the basis for a surprisingly accu­
rate assessment of the total periodontal status in a given
patient. 66,67
O'Leary's periodontal screening examination was
devised primarily as a diagnostic method for the gen­
eral practitioner. The dental arches are divided into six
segments so that the clinician can identify areas requir­
ing treatment. Gingival and periodontal status as well
as local irritants are assessed in each of the segments.
While there are many other indices it is beyond the
scope of this paper to survey them. The reviews of
54 55 56
H a z e n , Stratford and M a r g o l i s will prove helpful
to those interested in pursuing the subject.
RADIOLOGIC EXAMINATION
Next to periodontal probing the radiographic exami­
nation is probably relied on more in periodontal diag­
J. Periodontol.
September, 1977
nosis than any other technique. This is not surprising
since the x-ray film provides information that can be
attained no other way. While the periodontist is well
aware of the value of the radiograph he is also cogni­
zant of its many limitations. Unfortunately, some prac­
titioners depend upon the radiograph as the basic in­
strument for recognizing the presence or absence of
periodontal disease. T o do so introduces consistent
error into data gathering since the radiograph cannot
be utilized for the diagnosis of many periodontal le­
69,72
sions.
In discussing the limitations of radiographs Prichard
73
states:
1. Roentgenographs do not show the periodontal
pocket.
2. They do not specifically distinguish between the
successfully treated case and the untreated case.
3. They do not record the morphology of bone de­
formities.
4. They do not show the structures on the buccal,
lingual and labial aspects of the tooth.
5. They show no soft-to-hard tissue relationships.
6. They do not record tooth mobility.
Recent studies have brought the interpretation of
radiographs into sharper focus. G o l d m a n and co-work­
ers showed that large amounts of bone tissue could be
removed from the jaws without great changes being
74
discerned in radiographs of the area. Bender and
Seltzer produced experimental lesions in bone and
found that trabecular bone can be removed extensively
without obvious radiographic change. However, if the
junction where trabecular bone and cortical plate met
75,76
was disturbed then such change became a p p a r e n t .
Schwartz and Foster also carried out studies on dried
human mandibles and their findings concurred with
64,65
those of Bender and Seltzer. In addition, they found
that a 3-wall intrabony pocket-type defect could be
created with a number 6 round bur and the septum
removed from between the roots of a lower second
molar with the radiograph failing to show the destruc­
77
tion.
In a study of radiographic interpretation of periodon­
tal osseous lesions in skulls, Rees, Biggs and Collings
found that proximal and furca defects could be identi­
fied with a high degree of accuracy in the radiograph.
This was not true, however, of bony lesions on the
70
facial or lingual surfaces of the teeth. The finding by
Rees and co-workers that furca involvements can be
visualized is not in conflict with the Schwartz and Fos­
ter finding that interradicular bone can be removed
68
without radiographic change. In the latter case the
cortical bone was not disturbed while in periodontal
furca involvements it is.
Research continues to expand ttie information that
can be attained from radiographs. One radiologic study
has demonstrated that nutrient canals are found more
frequently: (1) in black patients; (2) in patients with
hypertension, and (3) when periodontal bone loss pro­
78
gresses. Another has attempted to relate the metacar-
Volume 48
Number 9
79
pal index to alveolar bone loss in periodontal disease.
Densitometry has also been suggested as having radio­
graphic potential in determining small dimensional
bone alterations and may prove valuable in assessing
80
variations in trabecular patterns. One method for
determining the topography of interproximal bony le­
sions utilizes 3 films taken at varying degrees of angula­
tion. The authors report that comparison of the 3 films
enables the clinician to determine if buccal or lingual
81
bone destruction is greater.
One of the important concerns of the periodontist is
how one is able to take follow-up radiographs compara­
ble to the original. The long-cone technique has proven
extremely helpful in this regard but has not eliminated
the problem entirely. Prichard emphasizes correct tech­
nique and feels that the most difficult part of any oral
73
examination is the making of radiographs. Various
methods have evolved which aim at standardizing den­
82-84
tal radiographs. Often these are more time consum­
ing than routine surveys and some require special
equipment. Perhaps for these reasons, no approach to
standardization has enjoyed wide-spread acceptance.
With insurance carriers relying heavily on radio­
graphs for authorization prior to dental care, the qual­
ity of radiographs assumes even greater importance. A
review of radiographs submitted to a third party carrier
has revealed that of 1000 cases, 7 5 % were unsatisfac­
tory, either due to improper mounting or technical
85
deficiencies.
Burnett has called attention to many of the errors
that lead to radiographs of poor quality. H e states that
the average dental film is not diagnostically accurate
and cautions that over-dependence upon radiographs
86
results in faulty diagnosis.
ATTACHED GINGIVA
The necessity for either establishing or preserving an
adequate zone of attached gingiva has been suggested
87
by Lang and Löe. These investigators have presented
evidence that areas with less than 1 mm of attached
gingiva tend to stay inflamed with or without detectable
plaque being present. Bowers had previously shown
that some cases with less than 1 mm of attached gingiva
may remain clinically healthy but stressed that such
areas require meticulous oral hygiene to prevent in­
88
flammation. Most periodontists would agree that "ad­
equate" attached gingiva enhances periodontal health
and therefore they include assessment of this anatomi­
cal feature in their examination.
Recent work has shown that children are often sub­
ject to gingival recession and that this aberration is
related to eruption patterns, width of the alveolar proc­
ess, and a reduced amount of attached gingiva. The
present trend is to correct deficiencies in attached gin­
89,92
giva by gingival grafting as a preventive measure.
Ascertaining the width of the attached gingiva may
sometimes prove troublesome since its apical border
(mucogingival junction [MGJ]) is often indistinct. A
biometric comparison of three methods for determining
Periodontal Diagnosis 537
the M G J has been accomplished. This study identified
the M G J (1) anatomically, (2) histochemically and (3)
functionally (tissue movability). It was concluded that
the functional M G J was located more apically than
9 3
were the anatomical and histochemical M G J ' s . F r o m
a clinical standpoint the rolling up of the alveolar mu­
cosa with the side of a periodontal probe assists in
identifying where this mucosa ends and the attached
91
gingiva begins. The difficulty in assessing the width of
attached gingiva was emphasized by Vincent and co­
94
workers in 1976. These investigators urged caution
when a determination is made relative to adequacy of
attached gingiva in children. Their work demonstrated
hazards in identifying attached gingiva and also showed
that as age increases there is a definite increase in the
width of attached gingiva.
Somewhat related to the diagnosis of problems re­
lated to the attached gingiva is the mucobuccal fold
depth. Ward has shown with a radiographic technique
that this depth can vary from 2.5 to 11.5 mm in the
lower anterior region. The author suggests that the
main reason for deepening the vestibular fornix would
be to provide room for an increase in attached gingiva
rather than for oral hygiene purposes. Healthy gingiva
was noted in cases with minimum depth of the vesti­
bule.95
CONCLUSIONS
A s with any diagnostic skill, periodontal diagnosis
involves a composite of data gathering. Case history,
laboratory testing, oral inspection, probing and radio­
logic examination all contribute to the data base from
which conclusions relative to diagnosis and therapy are
drawn. However, each technique is encompassed by
limitations that preclude reliance upon it to the exclu­
sion of others.
In surveying the present art of periodontal diagnosis
one factor stands out above all others. That is the
inability to determine whether or not active periodontal
destruction is occurring. While locating a deepened
crevice has been the traditional way of assessing peri­
odontal breakdown, modern knowledge tells us that
the problem is more complicated than that. Soon there
must be devised an acceptable method of ascertaining
which periodontal pockets are active and which are
quiescent. A s pointed out in this brief review, progress
in this direction is being made by studying neutrophile
migration, crevicular fluid, and bleeding characteristics
along with the classical signs of clinical inflammation. It
is not illogical to assume that the periodontist and other
dentists treating periodontal disease may, in the near
future, send patients to a clinical pathology laboratory
and receive a report on periodontal disease activity.
Neither is it illogical to conceive of the dentist being
able to determine gingival inflammatory activity
through bacteriological and other clinical testing in his
office. Perhaps the greatest hindrance to this approach
is the difficulty in arriving at a consensus among practi­
tioners as to (1) what test is the most accurate and (2)

538 Hurt
how such testing can be implemented with a minimum
of disruption in office routine. W i t h the need so evident
one would suspect these obstacles may be resolved
rather quickly.
In conclusion it is acknowledged that this review is,
of necessity, abbreviated. A n attempt has been made to
stress the more important issues as perceived by the
author. In doing so, some extremely worthy diagnostic
areas such as bacteriology, occlusion, mobility of teeth
and photographic methods of diagnosis have been
omitted. It is recognized that an unabridged review
would certainly include these facets of diagnosis.
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Volume 48
Number 9
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