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 247

Relationship Between Position of

Probe Tip and Periodontal Tissues
After Periodontal Surgery in Dogs

Yoshiyuki Hatakeyama, DDS, MS*/Mehmet Ilhan Uzel, DMD, DSc**/ The periodontal probe is mainly used
Ronaldo B. Santana, DMD, DSc*/Morris P. Ruben, DDS, FACD, FICD*** to explore and measure gingival sul-
cus or pocket depth to quantify den-
The aim of this study was to investigate postsurgical periodontal probe penetration by tal plaque and calculus1 and gingival
using clinical information and histometric data. Thirty-eight three-walled defects were
inflammation2 to estimate the level
created in four dogs, then maintained for 3 months. Subsequently, 26 defects were sub-
of alveolar crest.3 Pocket depth mea-
jected to periodontal surgery (surgical group), while 12 defects served as controls. The
sured by a probe has been an impor-
dogs were sacrificed at 4, 8, 12, and 16 weeks. Immediately before sacrifice, endodontic
silver points were placed in the gingival crevices as substitutes for periodontal probes tant component of the determina-
and fixed on the teeth. Following block sections, histologic and histomorphometric eval- tion of prospective treatment.
uations were undertaken: location of the probe tip in relation to the apical termination of Probing depth (PD) rarely coin-
the junctional epithelium, length of new junctional epithelium in relation to the apical cides with histologic gingival sulcus
junctional epithelium, and mean length of connective tissue adhesion in relation to the depth or periodontal pocket depth.
apical junctional epithelium. Probe tips were located –1.37 ± 1.73 mm and –0.20 ± 0.15 For instance, the probe tip stops at
mm apical to the apical junctional epithelium for the surgical and control groups, respec-
the level of intact connective tissue
tively, at 4 weeks, while the probe tip was located 0.58 ± 0.31 mm and 0.40 ± 0.20 mm
fibers an average of 0.25 to 0.40 mm
coronal to the apical junctional epithelium, respectively, at 16 weeks. Length of new
junctional epithelium in relation to apical junctional epithelium was significantly less for apical to the most apical cells of junc-
the surgical than the control group at 4 weeks (0.73 ± 0.60 mm vs 1.19 ± 0.02 mm) and tional epithelium in untreated pock-
8 weeks (1.77 ± 0.52 mm vs 2.15 ± 0.00 mm). There were no significant differences ets.4–9 In addition, the linear rela-
between the groups in regard to connective tissue relationship to the apical junctional tionship between Gingival Index and
epithelium. Periodontal probing is not recommended for at least 2 months after surgical resistance of the gingival tissues to
procedures; before this stage, probing forces may damage the soft tissue–tooth interre- probe penetration may alter PD if
lationship. (Int J Periodontics Restorative Dent 2005;25:247–255.)
probing force is not controlled and
tissue condition is not taken into
*Department of Periodontology and Oral Biology, Boston University, Goldman consideration.10–12 When probing
School of Dental Medicine. force is switched from 25 to 75 N,
**Assistant Professor, Department of General Dentistry and Department of Periodon-
tology and Oral Biology, Boston University, Goldman School of Dental Medicine.
the difference is 2 mm in PD in 60%
***Professor Emeritus, Department of General Dentistry and Department of Periodon- of pockets,13 which may dramatically
tology and Oral Biology, Boston University, Goldman School of Dental Medicine. affect treatment planning.
Therefore, the probing force
Correspondence to: Dr Mehmet Ilhan Uzel, Department of General Dentistry,
Boston University, Goldman School of Dental Medicine, 100 East Newton Street, should be standardized for
G-619, Boston, Massachusetts 02118. Fax: + (617) 414-1061. e-mail: uzel@bu.edu controlled and more accurate PD

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248
measurements.14–17 The most stan-
dardized probing force is 25 lb with
a probe tip diameter of 0.35
mm. 7,10,14,16–20 Optimal probing
force is suggested to be 0.75 N with
a probe tip diameter of 0.63
mm.13,21–23 When the diameters of
the probes are normalized to the
forces applied, a force of 25 g with
a probe tip diameter of 0.35 mm
can be expressed as 260 N/cm2, and
0.75 N with a probe tip diameter of
0.63 mm can be expressed as 240
N/cm2. Thus, actual probing force
per unit is similar in these different
standardized probing systems.
Similarly, the pressure used to place
the probe tip is calculated as approx-
imately 50 N/cm2 and 200 N/cm2 at
the base of the periodontal sul-
cus/pocket and at the base of the
junctional epithelium, respectively.24
The correlation between probe
penetration and degree of inflam-
mation in the connective tissue is
well-established.7,10,14,16–18,25 The
existence of ulceration in pocket
walls or extremely thin probes have
been suggested as reasons for pen-
etration into junctional epithe-
lium,25 although the periodontal
probe does not necessarily sepa-
rate epithelial attachment from the
tooth.14,18 Interestingly, the probe
tip remains coronal to the apical
termination of the junctional epithe-
lium (ATJE) in nonsurgically treated
pockets, whereas it penetrates api-
cal to ATJE in nontreated sites.26
To date, the relationship between
surgically treated pockets and post-
surgical probe penetration has not
been clearly established in a con-
trolled histometric study.
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In addition, the wound-healing Method and materials
process is an important stage in peri-
odontal surgical treatment. Com- The study was carried out on four
pared with wound healing in the rest beagle dogs approximately 3 to 4
of the body, the process in the peri- years of age, weighing a mean of 16
odontium is special because of the kg. Two to 3 weeks before the exper-
existence of teeth surrounded by iment started, the periodontal con-
soft and hard tissues. The epithelial- dition of each dog was examined.
ization begins in 24 to 36 hours,27,28 Then, teeth were subjected to scal-
while new connective tissue forms 5 ing and prophylaxis to eliminate
to 6 days after injury. Although the visual signs of marginal gingivitis.
rate of epithelialization is consistent, The outline of the experimental pro-
the extent of ATJE along the root cedures was as follows.
surface is variable.29 Electron micro-
scopic observation of newly formed
epithelial attachment30–33 reveals
that it is similar to normal epithelial
attachment. Findings in human34–36
and animal31,37,38 histologic studies
demonstrate that the postsurgical
interface between the soft tissue and
tooth surface is established with a
thin, long junctional epithelium.
The inflammation of gingiva is
another variable that must be con-
sidered when evaluating the accu-
racy of PD measurements. Clinical
PD may alter because of the afore-
mentioned relationship between
Gingival Index and resistance of the
gingiva to probing.10 Less variability
of probing distance occurs at higher
forces.39 Thus, time-dependent eval-
uation of the correlation between
postsurgical clinical inflammation
and histometric probe penetration is
important.
Therefore, the aim of this study
was to clinically and histometrically
evaluate time-dependent periodon-
tal probe penetration into the peri-
odontal tissues following periodon-
tal surgeries.

Defect preparation and
maintenance
The dogs were anesthetized by intra-
venous injections of 5% sodium pen-
tobarbital. Before flap reflection,
Class V cavity preparations were
made mesial and/or distal of crowns
in the experimental areas. The cavi-
ties were filled with self-curing acrylic
resin and reserved for the retention
of metal strips, which were designed
to prevent spontaneous healing of
the lesions (Figs 1 and 2). Inter-
proximal areas of maxillary canines
and third incisors, and mandibular
canines and first premolars were
chosen for creation of three-walled
intrabony defects. The method was
a modification of those described
by Ellegaard et al.29 The main con-
cept was based on the creation of
three-walled defects and their early
complete epithelialization.
After reflection of mucope-
riosteal flaps, a total of 38 three-
walled intrabony defects were pro-
duced. Before the bone was
removed, a horizontal notch was
made at the level of the bony crest
on the root surface. The dimensions
of the defects were 3 mm buccolin-
gually, 3 mm mesiodistally, and 6
mm deep in the cervicoapical plane.
To prevent spontaneous healing, a
stainless-steel strip (0.05 mm ⫻ 2
mm ⫻ 12 mm) was well adapted
along the root surface of each tooth
by adding self-curing acrylic resin.
A vertical reference groove was
made on the enamel surface over
the Class V cavity to indicate the
exact location and angulation of the
narrow three-walled defect. The
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Fig 1 Facial (left) and proximal (right)
illustrations of defect dimensions (3 mm
buccolingually, 3 mm mesiodistally, 6 mm
deep) and insertion of No. 55 silver point
in cervicoapical plane.
metal strips were left in place for 4 to
5 weeks, then replaced with dental
floss to allow more plaque and cal-
culus accumulation. The depth of
each defect was measured from the
gingival margin to the estimated
bottom of the pocket with two dif-
ferent standardized forces before
and after removal of the metal strip.
In the first method, a probe tip with
a diameter of 0.4 mm was inserted
into the gingival crevice with a prob-
ing force of 25 g. In the second
method, a silver point (No. 55 Real
Silver Point, Pulpdent) was inserted
with 50 g of force (Fig 3).
Surgical debridement and
plaque control
Three months after defect creation,
surgical debridement of the defects
was performed. In each animal, one
quadrant was not debrided and was
reserved as a control site. Plaque
249
Fig 2 Representative clinical view of pre-
pared three-walled bony defect.
control for both experimental and
control sites started on the day of
surgical debridement; 0.12%
chlorhexidine gluconate solution
was used. Toothbrushing was started
the second week after surgery.
The depth and width of the
established defects were measured
with a graduated periodontal probe
(OW/23, Hu-Friedy). One quadrant
was randomly selected as a control
site for each dog. In this site, plaque
and calculus were removed, but nei-
ther subgingival scaling nor root
planing was performed.
Placement of silver points into
gingival crevices
On the day of sacrifice of each dog,
a standardized probing force of 50 g
was used to insert endodontic silver
points (0.55-mm tip diameter) into
the gingival crevices of both the
experimental and control sites as
Volume 25, Number 3, 2005
250
Fig 3 Representative clinical view of
insertion of No. 55 silver point with 50-g
force.
Fig 4 (right) Reference hard and soft tis-
sue areas used for histometric evaluation;
ATJE = most apical cells of junctional
epithelium; CJE = most coronal cells of
junctional epithelium.
substitutes for periodontal probe
tips. The location of the silver points
was determined by the vertical ref-
erence groove on the enamel so that
the points would not be misplaced in
the gingival crevices. An orthodontic
pressure gauge (0 to 100 g, Haldo)
was used to apply 50 g of force. The
silver point was then fixed to the
tooth using Duralay (Reliance Dental)
on the point and tooth (Fig 3).
Histologic evaluation
The dogs were sacrificed 4, 8, 12,
and 16 weeks after the surgical
debridement. Immediately before
sacrifice, endodontic silver points
were placed into the gingival
crevices as previously described.
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After sacrifice, the jaws were re-
moved, segmented, and fixed in
10% neutral formalin. The speci-
mens were then decalcified in 5%
nitric acid solution. Silver points were
removed just before paraffin embed-
ding. The blocks were sectioned into
8-µm serial sections, then stained
with hematoxylin-eosin and the
Mallory trichrome method.
Clinical and histomorphomet-
ric measurements
Gingival Index,1,2 tooth mobility,
pocket depth prior to surgery, size
of created defects, pocket depth
before and immediately after
removal of the metal strips, and
size of established defects were
recorded. Histomorphometric
analysis of the following parame-
ters was done under a light micro-
scope at 100⫻ magnification (Fig
4): (1) distance from indentation of
the “probe tip” silver point to the
most apical cells of junctional
epithelium (ATJE) (P – ATJE); (2)
distance from the most coronal
cells of junctional epithelium (CJE)
to ATJE, determining the length of
junctional epithelium (CJE – ATJE);
and (3) mean length of connective
tissue adhesion (ATJE – CT).
Statistical analysis
All of the data obtained from histo-
metric measurements were analyzed
with analysis of variance (ANOVA)
and further with the Scheffé method
for multiple comparisons. Correla-
tion coefficient among the individual
data was also analyzed.
Results
Histologic observation
All probe tips were located apical to
ATJE 4 weeks after surgery. The tips
penetrated the epithelium into the
connective tissue (Fig 5a). In one of
the specimens, probing destroyed
the newly developed soft tissue–
tooth interface as much as 4.4 mm
apically (Fig 5b). There was minimal
infiltration within epithelium and
subjacent connective tissue of the
specimens.
At 8 weeks, the probe tips were
located at approximately the same
 251

Figs 5a and 5b All probe tips were locat-

HN ed apical to the most apical cells of junc-
tional epithelium after surgery. In four of
five specimens, tips penetrated epithelium
into connective tissue (Fig 5a, left); in one
specimen, probing destroyed the newly HN
developed soft tissue–tooth interface as
much as 4.4 mm down to defect bottom
compared to control specimens (Fig 5b,
right). In this case, area next to probe
exhibited long connective tissue (CT)
adhesion of 3.6 mm, without definite layer T
T
of new cementum. There was minimal infil-
tration in epithelium and connective tissue.
When inflammation existed, it was limited
to marginal gingiva; T = tooth; HN = hori-
zontal notch; AB = alveolar bone. CT

CT

AB AB

Figs 5c and 5d All probe tips were locat-

ed coronal to the most apical cells of junc-
tional epithelium (Fig 5d, right). Location
of probe tip and thin new epithelial attach-
ment were comparable to healthy gingiva.
Thin, long junctional epithelium was inter-
posed between connective tissue (CT) and
root surface; T = tooth; HN = horizontal
notch; AB = alveolar bone.

HN

HN

CT

T
T

CT AB

level of ATJE. Only one specimen
showed epithelial perforation
caused by probing; in this case, the
degree of inflammatory infiltration
at the area of the gingival crevice
was greater. Altogether, the length
of epithelial attachment was greater
than in 4-week specimens.
The probe tips were mostly
located at the same level of ATJE at
12 weeks. The healing pattern in this
period was similar to that at 8 weeks.
In one specimen, the newly formed
connective tissue attachment and
new epithelial attachment were

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252

detached by probing, and perfora- respectively. There was a signifi-

tion of the epithelium was observed cant (P ⬍ .05) difference in CJE –
in two specimens; inflammatory infil- ATJE between the 4-week period
tration in the marginal gingiva was and the rest of the time points, with
greater than in specimens that did the distance increasing directly with
not have epithelial perforation. the length of the postsurgical
At 16 weeks, all probe tips were period.
located coronal to ATJE (Fig 5c). The Although there was no statistical
relationship between the location of significance (P ⬍ .05), the mean
the probe tip and new epithelial length of connective tissue adhesion
attachment was comparable to the (ATJE – CT) at the 4-week period
healthy, intact gingiva (Fig 5d). A was higher than that at the remain-
thin, long junctional epithelium was ing time points.
interposed between the connective The correlation between the his-
tissue and the root surface. Con- tometric measurements was also
nective tissue adhesion of up to 1.45 analyzed. There was a significantly
mm in length was observed; it was negative (r = –.758, P ⬍ .01) corre-
not interrupted by the probing in lation between P – ATJE and ATJE –
any instances. CT. Statistically significant correla-
tions were found between CJE –
ATJE and ATJE – CT (r = –.044, P ⬍
Histometric results .05), and between P – ATJE and CJE
– ATJE (r = .479, P ⬍ .05).
The mean distance between the
probe tip and ATJE (P – ATJE) 4
weeks postoperative was –1.37 ±
1.73 mm (range –0.05 to –4.40 mm),
indicating that the tip was apical to
ATJE. The mean P – ATJE distance
at 16 weeks was 0.58 ± 0.31 mm
(range 0.20 to 0.95 mm). The differ-
ence in P – ATJE distance between
4 and 16 weeks was statistically sig-
nificant (P ⬍ .05). There was a sig-
nificant (P ⬍ .05) and strongly posi-
tive (r = .822) correlation between
the location of the probe tip relative
to ATJE and the postoperative
period up to 16 weeks.
The mean length of new junc-
tional epithelium (CJE – ATJE) at 4,
8, 12, and 16 weeks was 0.73 ±
0.53 mm, 1.77 ± 0.47 mm, 1.74 ±
0.52 mm, and 1.59 ± 0.27 mm,

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 253

Table 1 Histomorphometric results (mm)*

P-ATJE CJE – ATJE ATJE – CT
Time (wk) Experimental Control Experimental Control Experimental Control
4 –1.37 ± 1.73a –0.20 ± 0.15 0.73 ± 0.60b,c,d 1.19 ± 0.02 1.24 ± 1.34 0.83 ± 0.40
8 –0.07 ± 0.21 –0.10 ± 0.00 1.77 ± 0.52b,c 2.15 ± 0.00 0.15 ± 0.12 0.13 ± 0.00
12 0.11 ± 0.26 0.38 ± 0.13 1.74 ± 0.57d 2.36 ± 0.85 0.14 ± 0.15 0.23 ± 0.40
16 0.58 ± 0.31a 0.40 ± 0.20 1.59 ± 0.27 1.47 ± 0.30 0.35 ± 0.55 0.20 ± 0.00
*Statistically significant difference (P ⬍ .05) between values with the same superscripted letter.
P-ATJE = distance between probe tip and most apical cells of junctional epithelium; CJE – ATJE = length of new junctional epithelium ; ATJE – CT = mean
length of connective tissue adhesion.

Discussion as 1 month after nonsurgical treat- created on the attachment appara-

This article defines clinical inflam-
mation patterns and histometric
position of the periodontal probe
following periodontal surgical pro-
cedures. The probe tip was consis-
tently found to be apical to the most
apical cells of the junctional epithe-
lium (ATJE) 4 weeks after surgery,
even at areas of minimal inflamma-
tion (Fig 5). In one instance, the
probing destroyed the weak epithe-
lial attachment relationship to the
root surface as much as 4.4 mm api-
cally.
The dentogingival unit demon-
strates definite resistance to peri-
odontal probe penetration as early
ment.9 Controlled probing forces of
15, 25, and 50 g applied on the peri-
odontal pockets immediately and 1,
2, 3, and 4 weeks after a single
episode of scaling and root planing
showed pocket reduction and
increase of clinical attachment level
3 weeks after root planing.17 Further
measurement of pocket depth 4 to
16 weeks after scaling and root plan-
ing with the same controlled forces
showed a decrease of pocket depth
at 4 weeks that was maintained up to
16 weeks.37
However, our study investigated
experimental surgical procedures
rather than scaling and root planing
alone. Therefore, the extent of injury
tus was more severe. Unlike scaling
and root planing, a larger surgical
wound and injury caused delayed
healing, followed by the postsurgical
probe penetration.
Moreover, histometric measure-
ments (Table 1) as well as histologic
observation (Fig 5) revealed more
details about postsurgical healing as
well as when surgical outcome
should be evaluated. This has great
importance for periodontal regen-
erative and prosthetic postsurgical
evaluations. A weak resistance
against probing at 4 weeks was
observed even in the absence of
inflammation. It has been suggested
that there is a relationship between

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254
the degree of probe penetration
and the degree of inflammation
of untreated periodontal tis-
sues 10,14,17,25 and nonsurgically
treated periodontal tissues.9,13 The
probe is located apical to ATJE
under minimal connective tissue
inflammation in untreated peri-
odontal disease, 10,14 although
inflammation is not the only factor
influencing the degree of probe
penetration into postsurgical tissue.
Rather, the maturation of the con-
nective tissue appears to be a factor.
Only 16-week specimens were
comparable to the healthy, intact
periodontium in terms of relation-
ship between the location of the
probe tip and ATJE. The probe did
not reach the level of ATJE. In this
study, a standardized 50-g probing
force was used to insert the probe
substitutes into the gingival crevices.
The probing force used is 260
N/cm2, similar to the most widely
applied controlled probing force in
the literature (between 240 and 260
N/cm2).2,10,13,14,16–22 Therefore, the
destruction of the new periodontal
attachment at 4 weeks in the present
study should not be related to exces-
sive probing.
The suggested time for the
postoperative evaluation of the peri-
odontium by probing varies from a
few weeks to 3 to 4 months. The
results from the present study sug-
gest that probing should not be per-
formed for at least 8 weeks after sur-
gical procedures intended to
produce new attachment in intra-
bony defects.
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Volume 25, Number 3, 2005