/ Clin Periodontol }9%: 23: 240-250 Copyright ^- Munks^aarcl 1996

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periodoiitoloyy
ISS,\ IIM>.^-MT>

Niklaus P. Lang and

Periodontal diagnosis in treated Maurizio S. Tonetti
Department of Periodontology and Fixed
Prosthodontjcs, School ot Dental Medicine,

periodontitis Univereity of Beme, Berne, Switzertand

Why, when and how to use ciinical parameters

Lang NP, Tonetti MS: Periodontal diagnosis in treated periodontitis. Why, when
and how to use clinical parameters. J Clin Periodontol 1996: 23: 240-250.
© Munksgaard, 1996.

Abstract. The objective of clinical periodontal diagnosis in maintenance patients

is to monitor the risk for periodontal disease progression. Risk for progression
should be continuously monitored at the patient, tooth and site level at each
recall appointment. At the patient level, the significance of systemic diseases, ciga-
rette smoking, compliance with the recall program, loss of support m relation to
the patient"s age. full mouth plaque and/or bleeding scores, and prevalence of
residual pockets are of key importance. At the tooth and tooth-site levels, residual
periodontal support, inflammatory parameters and their persistence, presence
of ecological niches with difficult access such as furcations, and presence of iatro-
genic factors have to be put into proportion with the patient's overall risk profile.
The information gathered by clinical monitoring and continuous multilevel risk
assessment facilitates an immediate appreciation of the periodontal health status
Key words: diagnosis; risk assessment;
of an individual and the possible risk for further infection and/or disease pro-
periodontal diseases; clinicai moniioring;
gression in the dentition and at a particular tooth or site. periodontal maintenance

Clinical periodontal diagnosis relies (i,e. of untreated patients) thus repre-

Clinical Diagnosis for Different
Circumstances
Periodontal diseases are a variety of
pathological conditions of the tooth
supporting structures characterized by
the presence of a bacterial challenge eli-
citing a potentially destructive host re-
sponse. The pathognomonic feature of
periodontitis is the destruction of the
coliagenous fibers of the periodontal
ligament, which may result in loss of
bone support of the tooth. Clinically,
the condition is defined as measurable
loss of clinical attachment in relation to
the cemento-enamel junction. This is
associated with the presence of an in-
flammatory reaction which, clinically, is
recognized as bleeding, erythema,
edema and occasionally suppuration
out of the marginal periodontal tissues.
Other commonly identified signs in-
clude periodontal pocket formation, re-
cession of the gingival margin and
eventually radiographic alveolar bone
loss.
upon the assessment of the signs and
symptoms mentioned in an attempt to
establish the prevalence and severity of
disease in a dentition. It has to be real-
ized, however, that based on clinical
parameters, periodontal diagnosis can
only be established well after the bio-
logic onset of the disease process (Fig.
1). This, in turn, means that it is un-
known to the therapist, and somehow
irrelevant, whether or not the disease is
still "progressing". If the answer is yes,
at which rate and in which sites of the
dentition loss of attachment is induced
also remains obscure. Also, the time of
onset is unknown as it is unknown
whether or not the disease is in a period
of biological remission and thus char-
acterized by stability of chnical par-
ameters. In essence, detection of disease
mandates appropriate treatment and,
with few exceptions, more sophisticated
diagnostic procedures will not influence
the treatment approach chosen by the
therapist. Initial periodontal diagnosis
sents the clinical assessment of disease
extent and severity by time.
In this respect, a simple classification
of periodontal conditions will include
(Attstrom & Van der Velden 1994); (i)
gingigivitis; (ii) adult periodontitis; (iii)
early onset periodontitis; (iv) necrotiz-
ing periodontitis. Additional secondary
descriptors may further characterize the
conditions provided that appropriate
and relevant information is available
(Attstrom & Van der Velden 1994).
Different diagnostic issues have to be
raised following appropriate therapy.
These are based upon the long-term
overall objectives of periodontal ther-
apy, i.e., the preservation of a function-
ally adequate level of periodontai
attachment to maintain an individually
acceptable dentition for a lifetime. It is
generally accepted that such a treat-
ment goal may be achieved through the
pivotal role of combined efforts for op-
timal regular plaque control by the pa-
tient and the responsible professional

Eatly Usual
Biologic Diagnosis Clinical Outcome
Onset Possible Diagnosis
Clinical threshold
of detection
Time
Fig. I. Limitations of clinical diagnosis. Clinical diagnosis of periodontal disease requires
presence of a loss of attachment greater than the clinical threshold of detection. The diagram
should not be interpreted to illustrate a specific pattern of disease progression.
team. Frequently, it is observed that the the years to come. The relevant ques-
professional teatn focuses on the mere tion would, therefore, be which clinical
execution of the retnoval of the etiologic parameters may serve as early indi-
lactors and their retaining niches, here- cators for a new onset or recurrence of
by forfeiting the clinically retrievable di- the periodontal disease process, i.e. re-
agnostic information that is the scien- infection and progression of peri-
tific basis of supportive periodontal odontal breakdown of a once treated
care. periodonta] site.
It is the purpose of this review to The objective of clinical diagnosis
elucidate the principles of clinical diag- during supportive care is to identify and
nosis during supportive care of peri- assess disease progression in a given pa-
odontally treated patients. tient, a certain tooth or a particular site
of the dentition. Since in light of the
present knowledge, the biologic onset of
Continuous Multilevel Risk disease progression cannot be deter-
Assessment mined with a single parameter (deter-
ministic model), an alternative ap-
As opposed to an initial periodontal di-
proach to the prediction of such events
agnosis which considers the sequelae of
the disease process, i.e.. documents the must be based on probability calcu-
loss of periodontal attachment and the lations (probabilistic model). The latter
concomitant formation of periodontal approach is based upon the identifi-
pockets and development of inflam- cation and assessment of significant fac-
mation, clinical diagnosis during sup- tors associated with disease pro-
portive care has to be based on the vari- gression, i.e., risk factors or markers
ations of the health status obtained fol- (Beck 1990).
lowing successful active periodontal From a clinical point of view the sta-
treatment. This, in turn, means that a bility of periodontal conditions reflects
new baseline will have to be established a dynamic equilibrium between bac-
once the treatment goals of active peri- terial aggression and effective host re-
odontal therapy are reached and peri- sponse. As such, this homeostasis is
odontal health is restored (Claffey prone to sudden changes whenever one
1991). This baseline includes the level of of the two factors prevails. Hence, it is
clinical attachment achieved, while the evident that the diagnostic process must
inflammatory parameters are supposed be based on a continuous monitoring of
to be under control. Under optimal cir- the multilevel risk profile. The intervals
cumstances, supportive periodontal between diagnostic assessments must
care would maintain clinical attachment also be chosen based on the overall risk
levels obtained after active therapy for profile and the expected benefit. It must
Clinica! periodontal diagnosis 241
be understood that, so far, clinica! risk
assessment has also been demonstrated
to be very cost-effective {Axelsson &
Lindhe 1981a, b, Axelsson et al, 1991).
It should be recognized that, by vir-
tue of their previous disease prevalence,
all patients under a periodonta! main-
tenance regime represent a population
with a moderate to high risk for recur-
rent periodontal infection. As opposed
to the general population without such
a history, periodontal patients are re-
quired to participate in a well organized
recall system which should provide both
continuous risk assessment and ade-
quate supportive care. Without this, the
patients are most likely to experience
progressive loss of periodontal attach-
ment (Axelsson & Lindhe 1981a, Kent
1981, Becker et al, 1984, Cortelhni et al.
1994, Cortellini et ai, 1996). On the
other hand, it is important to determine
the level of risk for progression in each
individual patient in order to be able to
determine the frequency and extent of
necessary professional support to main-
tain the attachment levels obtained fol-
lowing active therapy The determi-
nation of such risk level would thus pre-
vent undertreatment, but also excessive
overtreatment during maintenance
(Braggeret al, 1992).
Significant factors for the multilevel
risk assessment will be discussed at the
subject, tooth and the tooth site level.
The sequence of enumeration does not
follow established priorities, but follows
the clinical sequence of their assess-
ment.
Subject Risk Assessment
Systemic conditions
The most substantiated evidence for
modification of disease susceptibility
and/or progression o( periodontal dis-
ease arises from studies on insulin de-
pendent and non-msulin dependent dia-
betes mellitus populations (Gusberti et
al. 1983. Emrich et al. 1991, Genco &
Loe 1993).
It has to be realized that the impact
of diabetes on periodontal diseases has
been documented in patients with un-
treated periodontal disease, while, as of
today, no clear evidence is available for
treated patients. It is reasonable, how-
ever, to assume that the influence of the
systemic conditions may also affect re-
currence of disease.
Research on the association and/or
modifyitig influence in susceptibility
and progression of periodontitis of
242 Lang & Tonetti
physical or psychological stress is
sparse (Cohen-Cole et al. 1981. Green
et al. 1986, Freeman & Goss 1993). The
hormonai changes associated with these
condition, however, are well docu-
mented (Selye 1950).
Changes in female sex hormones
during puberty and pregnancy have
also been shown to select for peri-
odontitis associated bacteria (Korn-
man & Loesche 1980. Mombelli et al.
1990). However, no associations be-
tween hormonally induced bacterial
changes and the pathogenesis of peri-
odontitis could be established in con-
trolled clinical trials.
Compliance with a recall system
Several investigations have indicated
that only a minority of periodontal pa-
tients comply with the prescribed sup-
portive periodontal care (Wilson et al.
1984, Mendoza et al. 1991. Checchi et
al. 1994, Demetriou et al. 1995). Since it
has been clearly established that treated
periodontal patients who comply with
regular periodontal maintenance ap-
pointments have a better prognosis
than patients who do not comply (Ax-
elsson & Lindhe 1981a. Kent 1981.
Becker et al. 1984. Cortellini et al. 1994.
Cortellini et al. 1996). non compliant or
poorly compliant patients may be con-
sidered at higher risk for periodontal
disease progression. A report that inves-
tigated the personality differences of
patients participating in a regular recall
program as compared to patients who
did not. revealed that patients that did
not take part in a maintenance program
following periodontal therapy had
higher incidence of stressful life events
and less stable persona! relationships in
their lives (Becker et al. 1988). Prospec-
tive identification of non compliant pa-
tients, however, has been elusive: pre-
vious history of non compliance being
the best prognostic indicator.
Environmental exposures
There is increasing evidence in the
literature that consumption of tobacco,
predominantly in the form of smoking
rather than snuffing or chewing, affects
the susceptibility and the treatment
outcome of patients with adult peri-
odontitis. Classical explanations for
these observations have included the
association between smoking habits
and poor oral hygiene as well as un-
awareness for general health issues
(Pindborg 1949. Rivera-Hidalgo 1986).
More recent evidence, however, has es-
tablished that smoking "per se" repre-
sents not only a risk marker, but prob-
ably a true risk factor for periodontitis
(Ismail et al. 1983. Bergstrom 1989,
Bergstrom et al. 1991, Haber et al.
1993). In a young population (19 to 30
years of age). 51 to 56% of the ob-
served periodontitis was associated
with cigarette smoking (Haber et al.
1993). The association of smoking and
periodontitis has been shown to be
dose-dependent (Haber et al. 1993). It
has also been shown that smoking will
affect the treatment outcome after
scaling and root planing (Preber &
Bergstrom 1985). moditied Widman
flap surgery (Preber & Bergstrom
1990), and regenerative periodontal
therapy (Tanetti et ai. 1995). Further-
more, a high proportion of so-called
refractory patients has been identified
to consist of smokers (Bergstrom &
Blomlof 1992). The impact of cigarette
smoking on the long term effects of
periodontal therapy in a population
undergoing supportive periodontal
care has been recently reported.
Smokers displayed less favorable heal-
ing responses both at re-evaluation
and during a 6 years period of sup-
portive periodontal care (Baumert-Ah
et al. 1994). In spite of the paucity of
evidence relating cigarette smoking
with impaired outcomes during sup-
portive periodontal care, it seems
reasonable to incorporate heavy
smokers (>10 cigarettes/day) in a
higher risk group during maintenance.
With increasing age the general
population is and will be exposed to in-
creasing numbers of medications for
prolonged periods of time. Some of
these drugs may affect the periodontal
status by either directly interfering with
the periodontal tissues, or indirectly af-
fecting the host reponse or plaque for-
mation rates (Holm-Pedersen 1994). In
spite of the fact that several studies on
immunosuppressed patients have been
performed in the 1970s (Schuler et al.
1973), there is lack of sufficient data to
associate any medication with an in-
creased risk of disease progression dur-
ing maintenance. On the other hand. It
is evident that medically seriously com-
promised patients may belong to a
group of high risk patients in which
control of periodontal infections is
aimed at prevention of .systemic compli-
cations rather than preservation of the
dentition.
Loss of periodontal support in relation to
tiie patient's age
The extent and prevalence of peri-
odontal attachment loss (i.e. previous
disease experience and susceptibility),
as evaluated by the height of the al-
veolar bone on radiographs, may repre-
sent the most obvious indicator of sub-
ject risk when related to the patient's
age. In light of the present understand-
ing of periodontal disease progression,
and the evidence that both onset and
rate of progression of periodontitis
might vary among individuals and dur-
ing different time frames (Van der
Veiden 1991), it has to be realized that
previous attachment loss in relation to
the patient's age does not rule out the
possibility of rapidly progressing
lesions. Therefore, the actual risk for
further disease progression in a given
individual may occasionally be under-
estimated. Hopefully, the rate of pro-
gression of disease has been positively
affected by the treatment rendered and
hence, previous attachment loss in re-
lation to patient's age may be a more
accurate indicator during supportive
periodonta! care than before active
periodontal treatment. Given the hypo-
thesis that a dentition may be func-
tional for the most likely life expectancy
for the subject in the presence of a re-
duced height of periodontal support
(i.e. IS-Sff'A, of the root length), the risk
assessment in treated periodonta] pa-
tients may represent a reliable prognos-
tic indicator for the stability of the
overall treatment goal of keeping a
functional dentition for a lifetime (Pa-
papanou et al. 1988).
Oral hygiene (full mouth plaque record)
Since bacterial plaque is by far the most
important etiologic agent for the occur-
rence of periodontal diseases (for re-
view, see Kornman & Loe (1993)), it is
evident that the full mouth assessment
of the bacterial load must have a pivotal
impact in the determination of the risk
for disease recurrence. It has to be real-
ized, however, that regular interference
with the microbial ecosystem during
periodontal maintenance will eventually
obscure such obvious associations. In
patients treated with various surgical
and non-surgical modalities, it has
clearly been established that plaque in-
fected dentitions will yield recurrence of
periodontal disease in multiple loca-
tions, while dentitions under plaque

control and regular supportive care
maintain periodontal stability for many
years (Rosling et al. 1976, Axelsson &
Lindhe 1981a, b). Similar observations
were made following regenerative pro-
cedures (Cortellini et al, 1994). Studies
have, so far, not identified a level of
plaque infection compatible with main-
tenance of periodontal health. How-
ever, in a clinical set-up, a plaque con-
trol record of 20 to 40"/. might be toler-
able by most patients. It is important to
realize that the full mouth plaque score
has to be related to the host response of
the patient, i,e,, compared to inflam-
matory parameters,
% of sites with bleeding on probing
Bleeding on gentle probing represents
an objective inflammatory parameter
which has been incorporated into index
systems for the evaluation of peri-
odontai conditions (Loe & Silness 1963,
Muhlcmann & Son 1971) as well as
used as a parameter by itself. Although
there is no established acceptable level
of prevalence of bleeding on probing in
the dentition above which a higher risk
for disease recurrence has been estab-
lished, a BOP prevalence of 25"';. has
been the cut-off point between patients
with maintained periodontal stability
for 4 years and patients with recurrent
disease in the same time frame in a pro-
spective study in a private practice (Joss
et al. 1994), Further evidence of BOP
percentages between 20 and 30% deter-
mining a higher risk for disease pro-
gression originates from studies of
Claffey et al, (1990) and Badersten et
al, (1990).
In periodontal maintenance individ-
uals with low mean BOP percentages
{<10% of the surfaces) may be con-
sidered as patients with a low risk for
recurrent disease (Lang et al, i990),
while patients with mean BOP percen-
tages greater than 25% should be sched-
uled for prophylactic supportive peri-
odontal therapy more f^requently Of
course, the history and the response to
therapy in relation to the patient's age
should also be considered.
Prevaience of residuai pockets greater
Vnan 4 mm
The enumeration of the residual
pockets with probing depth greater
than 4 mm represents, to a certain ex-
tent, the degree of success of peri-
odontal treatment rendered. Although
this figure per se does not make much
sense when considered as a sole par-
ameter, the evaluation in conjunction
with other parameters such as bleeding
on probing and/or suppuration will re-
flect existing ecological niches from and
in which re-infection might occur. It is,
therefore, conceivable to assume that
periodontal stability in a dentition
would be reflected in a minimal number
of residual pockets. Presence of high
frequencies of deep residual pockets
and deepening of pockets during sup-
portive periodontal care has, in fact,
been associated with high risk for dis-
ease progression (Badersten et al, 1990,
Claffey et al. 1990). On the other hand,
it has to be realized that an increased
number of residual pockets does not
necessarily imply an increased risk for
re-infection or disease progression,
since a number of longitudinal studies
has established the fact that, depending
on the individual supportive therapy
provided, even deeper pockets may be
stable without further disease pro-
gression for years (Knowles et al. 1979,
Lindhe & Nyman 1984),
Tooth Risk Assessment
Tooth position within the dentai arch
Early clinical surveys have associated
the prevalence and severity of peri-
odontal diseases with malocclusion
and irregularities of tooth position
(Ditto & Hall 1954, Bilimoria 1963),
However, many subsequent studies
using clinical evaluation methods
could not confirm these conclusions
(Beagrie & James 1962, Geiger 1962,
Gould & Picton 1966). Although a re-
lationship between crowding and in-
creased plaque retention and gingival
inflammation has been established (In-
gervaO et al. 1977, Buckley 1980, Grif-
fiths & Addy 1981, Horup et al, 1987),
no significant correlation between an-
terior overjet and overbite (Geiger et
al, 1973), crowding and spacing (Geig-
er et al, 1974) or axial inclinations and
tooth drifts (Geiger & Wasserman
1980) on one side and periodontal de-
struction, i,e,, attachment loss sub-
sequent to gingival inflammation,
could be established. It is evident from
the literature mentioned that crowding
of teeth might eventually affect the
amount of plaque mass formed in
dentitions with irregular oral hygiene
practices, thus contributing to the de-
velopment of chronic gingivitis, but, as
of today, it remains to be demon-
Clinical periodontal diagnosis 243
strated that tooth malposition within
the dental arch will lead to an in-
creased risk for periodontal attach-
ment loss. It has to be realized, how-
ever, that all the studies quoted incor-
porated patients with unknown risk
level for periodontal disease develop-
ment, while patients in periodontal
maintenance are, by definition, pa-
tients who had experienced attachment
loss. Hence, for periodontal patients
during maintenance it is not known
whether or not tooth irregularities
within the dental arch play a signifi-
cant role in disease progression. It is
understood that oral hygiene practices
and accessibility of niches resulting
from tooth malposition are determin-
ing factors for optimizing an individ-
ual program for adequate oral hy-
giene.
Mesiai tipping of posterior teeth
Tilted posterior teeth have often been
considered to create ecological niches
that will be conducive to colonization
with presumptive periodontal patho-
gens and hence, it was often proposed
by clinicians to eliminate these niches
by uprighting tilted molars (Stern et
al. 1981, Becker et al. 1982). In epide-
miological studies, however, only mi-
nor differences were found between the
periodontal health of tipped and non
tipped molars (Geiger & Wasserman
1980). Another survey (Ehrlich & Jaffe
1983) could not establish increased
risk for periodontal disease develop-
ment. More recently, a well designed
intra-individual retrospective study
analyzed the conditions around tipped
and upright molars (Lundgren et al,
1992). Out of 450 adults, 69 subjects
presented with molars tipped more
than 30 degrees and controlateral up-
right molars as controls. Besides the
occurrence of plaque and gingivitis,
pocket probing depths and alveolar
bone levels were registered using clin-
ical and radiographic parameters. Re-
gardless of the variables tested, no sig-
nificant differences were revealed be-
tween tipped and upright molars when
compared over a 15-year period. This
clearly indicates that tipped molars
probably are not more susceptible to
periodontal disease progression than
upright molars. But again, it remains
unclear whether or not tipped molars
would be at increased risk in patients
treated for advanced periodontal dis-
ease during maintenance.
244 Lang & Tonetti
Mouth breathing and extreme overjet
Only few studies have attempted to
correlate mouth breathing habits with
periodontal disease development and
no studies are available about pen-
odontal disease progression in treated
populations, it appears that extreme
anterior overjet (>6 mm) is associated
with increased gingival inflammation
(Geiger et al. 1973) and pocket forma-
tion (Helm & Petersen 1989).
In mouth breathers a significant cor-
relation between gingivitis and crowding
was found, while nose breathers exam-
ined by the same investigators showed no
such correlation (Jakobsson 1973).
Hence, it may be assumed that mouth
breathing may contribute to the develop-
ment of gingivitis by dehydrating the
tissues, especially in dentitions with in-
adequate plaque control.
Variations of tootti morphoiogy
The presence of variations in tooth
morphology, such as enamel pearls, en-
amel projections, hngual grooves, and
root depressions have frequently been
considered to be associated with devel-
opment of periodontal disease. It is ob-
vious that these aberrations provide
ecological niches which may or may not
be conducive to the establishment of a
microbiota associated with periodontal
disease (for review, see Kornman & Loe
(1993)). However, the accessibility of
such locations to cleaning devices and
the performance of adequate oral hy-
giene practices in these areas would ren-
der these variations inconspicuous and
insignificant for the disease process.
The question whether or not morpho-
logical variations represent a higher risk
for disease development and pro-
gression during maintenance has not
been addressed in controlled studies.
There are studies which attempted to
establish an association between e.g. en-
amel projections and enamel pearls in
multi-rooted teeth and the prevalence of
periodontal disease (Leib et al. 1967).
However, no conclusive evidence was
provided by this and subsequent
studies.
Furcation involvement
It is evident that multi-rooted teeth with
periodontal lesions extending into the
furcation area have been subject to in-
tensive therapeutic studies for many
years (Kalkwarf & Reinhardt 1988).
Retrospective analyses of large patient
populations in private periodontal prac-
tices of periodontal specialists (Hirsch-
feld & Wasserman 1978. McFall 1982)
have clearly established that multi-root-
ed teeth appear to be at high risk for
tooth loss during the maintenance
phase. The most impressive long term
documentation maintained 600 patients
for an average duration of 22 years, and
10°/ii of these patients were even main-
tained for more than 30 years (Hirsch-
feld & Wasserman 1978). While 83"',. of
the patients could be considered "well
maintained" and had lost only 0-3 teeth
during the observation period, a patient
group of 4°'n (25) was identified with an
extreme risk for disease progression and
had lost between 10 and 23 teeth during
a regularly scheduled maintenance pro-
gram. Irrespective of the patient group
of low. moderate, and high risk for dis-
ease progression during maintenance the
majority of the teeth lost were furcation
involved molars (Hirschfeld & Wasser-
man 1978). Similar results were obtained
in a study on 100 treated periodontal pa-
tients maintained for 15 years or longer
(McFall 1982).
Prospective studies on periodontal
therapy in multi-rooted teeth have also
revealed significant differences between
non molar sites and molar flat surfaces
on one side and molar furcation sites
on the other, when looking at the treat-
ment outcomes evaluated as bleeding
frequency, probing depth reductions
and levels of attachment (Nordland et
al. 1987). Again, teeth with furcation
involvement and original probing
depths >6 mm had reduced treatment
outcomes.
The assumption that the prognosis
for single rooted teeth and non fur-
cation involved multi-rooted teeth is
better than the prognosis for furcation
involved multi-rooted teeth has also
been confirmed by Ramfjord et al.
(1987) in a prospective study over 5
years. It has to be realized, however,
that these results are not intended to
mean that furcation involved teeth
should be extracted, since all the pro-
spective studies have documented a
rather good overall prognosis for such
teeth if regular supportive care is pro-
vided by a .well-organized maintenance
program.
latrogenic factors
Overhanging restorations and ill-fitting
crown margins certainly represent an
area for plaque retention, and there is
an abundance of association studies
documenting increased prevalence of
periodontal lesions in the presence of
iatrogenic factors (for review see Leon
1977). Depending on the supragingival
or subgingival location of such factors,
their influence on the risk for disease
progression has to be considered. It has
been established that slightly subgingi-
vally located overhanging restoration
will, indeed, change the ecological niche
providing more favorable conditions for
the establishment of a gram negative
anaerobic microbiota (Lang et al.
1983). There is no doubt that shifts in
the subgingival microflora towards a
more periodontopathic microbiota. if
unaffected by treatment, represent an
increased risk for periodontal break-
down.
Residual periodontal support
Although clinicians often express feel-
ings as to teeth wdth reduced peri-
odontal support not being able to
function either individually and hence,
express a need for tooth extraction or
splinting, there is clear evidence from
longitudinal studies that teeth with se-
verely reduced, but healthy, peri-
odontal support can function either in-
dividually or as abutments for many
years without any further loss of
attachment (Nyman & Lindhe 1979,
Nyman & Ericsson 1982). Hence, suc-
cessfully periodontally treated teeth
can he maintained over decades and
function as abutments in fixed bridge-
work or as individual chewing units
irrespective of the amount of residual
periodontal support, provided that
physiological masticatory forces do
not subject such teeth to a progressive
trauma which may lead to spon-
taneous extraction. Obviously, by
virtue of the already reduced support,
should disease progression occur in
severely compromized teeth, it may
lead to spontaneous tooth exfolia-
tion.
Mobility
In the light of the discussion of abut-
ment teeth with severely reduced, but
healthy periodontal support, tooth mo-
bility may be an indicator for progress-
ive traumatic lesions, provided that the
mobility is increasing continuously
(Nyman & Lang 1994). When assessing
tooth mobility, it has to be realized that
 Clinical periodonlal diagnosis 245

two factors may contribute to so called
hypermobility: (l) a widening of the
periodontal ligament as a result of uni-
or multi-directional forces to the crown,
high and frequent enough to induce re-
sorption of the alveolar bone walls: (ii)
the height of the periodontal support-
ing tissues. If this is reduced due to
prior periodontal disease, but the width
of the periodontal ligament is un-
changed, the amplitude of root mobility
within the remaining periodontium is
the same as in a tooth with normal
height, but the leverage on the tooth
following application of forces to the
crown is changed. Therefore, it has to
be realized that all teeth that had lost
periodontal support have increased
tooth mobility as defined by crown dis-
placement upon application of a given
force. Nevertheless, this so called hyper-
mobility should be considered as physi-
ologic (Nyman & Lindhe 1976).
the future may be predicted for sites re-
peatedly positive for bleeding on prob-
ing (Badersten et al. 1985, Lang et al.
1986, Vanooteghem et al. 1987, Bad-
ersten et al. 1990. Claffey et al. 1990,
Vanoothegem et al. 1990).
Obviously, bleeding on probing is
rather sensitive to different forces ap-
plied to the probe. An almost linear
relationship (if=0.87) existed between
the probing force applied and the per-
centage of bleeding sites in a study on
healthy young adults (Lang et al.
1991). If the probing force exceeded
0.25 N (25 g), the tissues are trauma-
tized and bleeding is provoked as a re-
sult of trauma, rather than as a result
of tissue alterations due to inflam-
mation. To assess the 'true' percentage
of bleeding sites due to inflammation,
a probing force of 0.25 N or less
should be applied which clinically
means a light probing force. This has
cussed: (i) dimension of the periodontal
probe; (ii) placement of the probe and
obtaining a reference point: (iii) crude-
ness of the measurement scale: (iv) prob-
ing force; (v) gingival tissue conditions.
Dimensions of tiie periodontal probe
It is obvious that different sizes of peri-
odontal probes will yield different pene-
tration depths into the periodontal
tissues, even if all other variables are
controlled. Hence, the use of probing
instruments with standardized dimen-
sions is a prerequisite for repeated
probing depth measurements. Usually,
periodontal probes with a point diam-
eter of 0.4-0.5 mm have been used suc-
cessfully.
Placement of the probe and obtaining a
reference point

Since tooth mobility is probably
more frequently affected by reduced
periodontai height rather than uni- or
multi-directional application of forces
onto the tooth, its significance for the
evaluation of the periodontal con-
ditions has to be questioned. Several
studies have indicated that tooth mo-
bility varies greatly before, during and
after periodontal therapy (Persson
1980, 1981a, b). From these studies it
can be concluded that periodontally in-
volved teeth showed a decrease in mo-
bility following non-surgical and/or sur-
gical periodontal procedures. However,
following surgery, tooth mobility may
temporarily increase during the healing
phase and may resume decreased values
later on. Provisional splinting as an ad-
junct to non-surgical or surgical ther-
apy does not seem to affect the final re-
sult of tooth mobility.
Site Risk Assessment
Bleeding on probing
Absence of bleeding on probing is a re-
liable parameter to indicate periodontal
stability if the test procedure for as-
sessing bleeding on probing has been
standardized (Lang et al. 1990). Pres-
ence of bleeding upon standardized
probing will indicate presence of gingi-
val inflammation. Whether or not re-
peated bleeding on probing over time
will predict the progression of a lesion
is, however, questionable (Lang et al.
1986, Vanooteghem et al. 1987, Lang et
a l 1990). Nevertheless, a 30% prob-
ability for attachment loss to occur in
also been confirmed for patients who Manual probing involves the variability
have experienced loss of attachment, of the measurements generated by dif-
i.e. with successfully treated advanced ferent angulation and site localization
periodontitis (Karayannis et al. 1991. of the probe and by the difficulty in ob-
Lang et al. 1991). taining a fixed landmark as a reference
Since absence of bleeding on probing point. Recently, electronic probes have
at 0.25 N indicated periodontal stability been developed to automatically locate
with a negative predictive value of 9S"A>- the cemento-enamel junction (Jeffcoat
99% (Lang et al. 1990), this clinical par- et al. 1991) which are able to measure
ameter is most reliable to monitor pa- attachment levels to a sensitivity of 0.1
tients over time in daily practice. Non- mm. This technique is still subjected to
bleeding sites may be considered as chnical trials and. in the light of other
periodontally stable. On the other variables, its advantage over conven-
hand, bleeding sites seem to have an in- tional probing cannot be determined at
creased risk for progression of peri- this time.
odontitis. especially when the same site
is bleeding at repeated evaluations over
time (Lang et al. 1986. Ciafley et al. Crudeness of the measurement scale
1990). Probing depth measurements are gener-
It is. therefore, advisable to register ally assessed to the nearest millimeter
the sites which bleed on probing (BOP) (Glavind & Loe 1967). It is evident that
in a dichotomous way using a constant even a measurable loss of attachment of
force of 0.25 N. This allows the calcu- 0.5 mm accepts a high incidence of false
lation of the mean BOP for the patient, negative values. This, in turn, means
but yields also the topographical loca- that "true" disease progression may ac-
tion of the bleeding site. Repeated tually occur, but only to a small extent
scores during maintenance will yield the which is not revealed by the crudeness
surfaces at higher risk for loss of of the measurement scale.
attachment.
Probing force
Probing depth and loss of attachment
Probing force is a significant variable
Clinical probing is the most commonly which should be controlled in order to
used parameter both to document loss obtain reproducible measurements of
of attachment and to establish a diag- probing depth. Although a wide range
nosis of periodontitis. There are. how- of 0.03-1.35 N has been identified for
ever, some sources of error inherent to examiners with different experience
this method which contribute to the (Gabathuler & Hassei! 1971) in a study
variability in the measurements. Among of 58 subjects, different professionals in
these, the following factors are dis- periodonties probed with an average of
246 Lang & Tonetti
0.44 N (Glavind & Loe 1967. Gabathul-
er & Hassell 1971. Freed et al. 1983).
No significant differences were found in
probing forces applied among the dif-
ferent professional groups (students,
general practitioners, periodontists.
dental hygienists). Significant differ-
ences were found, however, when inter-
and intra-examiner variability was ana-
lyzed. If a probing force of 0.25-0.3 N
is applied, the apical termination of the
probing tip lies usually within the junc-
tional epithelium in healthy gingival
tissues (Armitage et al. 1977.
Robinson & Vitek 1979. Poison et al.
1980. Fowler et al. 1982). This is the
reason why probing forces in this order
of magnitude have generally been ac-
cepted when using electronic pressure
sensitive probes. If treatment effects are
to be monitored the probing force will
influence the clinical attachment levels.
Also, it has been demonstrated that at
least 0.25 N of probing force has to be
applied in order to yield treatment re-
lated differences in clinical attachment
levels (Mombeili et al. 1992).
Gingival tissue conditions
Several studies have documented that
attachment level measurements are sig-
nificantly influenced by the density of
the connective tissue collar around the
teeth (Armitage et al. 1977, Fowler et
al. 1982).
In healthy tissues, or in slight gingi-
vitis, the probe tip generally reaches the
most apical cell of the junctional epi-
thelium. In a periodontal pocket, how-
ever, the probe tip routinely exceeds the
level of the connective tissue attach-
ment, penetrates into the inflamed
tissue and is hindered in its apical pro-
liferation by intact connective tissue
fibers or eventually by the alveolar bone
crest (Armitage et al. 1977). In gingival
health, however, the most apical cell of
the junctiona! epithelium may not al-
ways be reached if a tight adaptation of
the gingival tissues is obtained as a re-
sult of therapy (long junctional epithel-
ium). The significant influence of the in-
flammatory infiltrate on probing depth
measurements has, therefore, clearly
been documented.
Ciinical probing
In spite of the recognized method errors
inherent to clinical probing, this diag-
nostic procedure has not only been the
most commonly used, but also the most
reliable parameter for the evaluation of
the periodontal tissues. It has to be real-
ized that increased probing depth and
loss of probing attachment are par-
ameters which reflect the history of
periodontitis rather than its current
state of activity. In order to obtain a
more realistic assessment of the disease
progression or. more commonly, the
healing following therapy, multiple
evaluations should be performed. Obvi-
ously, the first evaluation prior to ther-
apy will yield results confounded by
greater measurement error than evalu-
ations following therapy. The reference
point (cement enamel junction) may be
obstructed by calculus or by dental res-
torations, and the condition of the gin-
gival tissues may allow an easy penetra-
tion of the periodontal probe into the
tissues, even though the probe position
and force applied are standardized.
These biological variables (tissue con-
ditions and calculus) may be minimized
following initial periodontal therapy
and hence, repeated periodontal evalu-
ations using probing will improve the
metric assessment. Therefore, the first
periodontal evaluation after healing fol-
lowing initial periodontal therapy
should be taken as the baseline for long
term clinical monitoring (Claffey 1994).
Periodontal probing is best per-
formed at six sites around each tooth.'
root (mesio-buccal. buccal. disto-buc-
cal, disto-lingual. lingual and mesio-lin-
gual) in two steps: (i) Determination of
the distance from the free gingival mar-
gin (FGM) to the cemento-enamel
junction (CEJ) to the nearest milli-
meter. For recognition of the CEJ. the
periodontal probe is angulated at 45° to
the long axis the root surface and
guided towards the CEJ. If recession is
present the value becomes negative, (ii)
Assessment of the probing pocket depth
(PPD) from the FGM to the bottom of
the pocket or sulcus to the nearest milli-
meter. The periodontal probe is only
slightly angulated (about 10°) and
guided along the root surface until the
first resistance of the gingival connec-
tive tissues is felt. Preferably, a stan-
dardized force (e.g. 0.25 N) is applied.
Probing attachment levels (PAL) are
calculated by algebraically subtracting
the values of step 1 (FGM-CEJ) from
the values of step 2 (PPD).
Suppuration
In a proportion of periodontal lesions
pus will develop and may drain through
the orifice of a pocket. This criterion of
suppuration may be recognized while
clinically probing the lesions or prefer-
ably, by using a ball burnisher (Singh et
al. 1977|. Several longitudinal studies
on the results of periodontal therapy
have evaluated clinical parameters, in-
cluding suppuration, for the prediction
of future loss of attachment (Badersten
et al. 1985. Badersten et al. 1990. Claf-
fey et al. 1990). In all these studies the
presence of suppuration increased the
positive predictive value for disease pro-
gression in combination with other clin-
ical parameters such as bleeding on
probing and increased probing depth.
Hence, following therapy a suppurating
lesion may provide evidence that the
periodontitis site is undergoing a period
of exacerbation (Kaldahl et al. 1990).
Clinical Implementation and Utility of
Continuous Multilevel Risk
Assessment
Practically all longitudinal studies on
periodontai therapy have documented
that successful treatment outcomes such
as resolution of inflammation, reduction
of probing pocket depths, and gain in
clinical attachment levels can only be
maintained by supportive therapy (for
review, see Wachtel (1994)). These
studies have implemented regular visits
for professional tooth cleaning as the
most important pre-requisite to assure
treatment results over time. All of these
studies, however, have u,sed stereotype
and standardized maintenance sched-
ules and protocols. There is no doubt
that, in some of the patients, the stan-
dardized supportive therapy for a clin-
ical trial may represent overtreatment.
while in others it may not suffice. The
present review attempted to focus on the
evaluation of the risk of the individual
patient following periodontal treatment
as a pre-requisite to guarantee mainten-
ance of periodontal attachment.
The 3 levels of risk assessment pre-
sented represent a logical sequence of
clinical evaluation to be performed
prior to rendering treatment during
maintenance. The information gathered
from a stepwise evaluation should not
impinge but rather improve the efficacy
of secondary prophylactic peridontal
care and treatment. A logical sequence
of checks and examinations may be eas-
ily obtained in a short period of time
and at no extra cost for laboratory
tests. The information obtained from
clinical monitoring and multilevel risk

assessment facilitates an immediate ap-
preciation of the periodontal health sta-
tus of an individual and the possible
risk for further infection and/or disease
progression.
Most longitudinal studies published
up to date have been based on single
level, i.e. site or tooth risk assessment,
rather than accounting for the most evi-
dent factor in risk assessment: the pa-
tient. Ample evidence indicates that a
minority of patients will continue to
present problems and. hence, com-
pletely differ from the maintenance pat-
tern visualized in the majority of the
patients. Even in the studies where this
fact has been explicitly addressed
(Hirschfeld & Wasserman 19781. the
factors which determined whether or
not a patient belonged to a well main-
tained group or to a group with con-
tinuous loss of periodontal attachment
have not been identified.
Based on the evidence emerging from
recent and ongoing studies this review
suggested risk factors to consider in or-
der to optimize the therapeutic efforts
during supportive periodontal therapy.
It is evident that some of the aspects
proposed have not yet been validated in
well controlled studies, but are being
addressed in a number of ongoing in-
vestigations around the world.
For the time being, it is suggested to
evaluate patients on the three different
levels mentioned. At the patient level loss
of support in relation to patient age. full
mouth plaque and/or bleeding scores,
prevalence of residual pockets are evalu-
ated together with the presence of sys-
temic conditions or environmental fac-
tors, such as smoking, which can influ-
ence the prognosis. The clinical utility of
this first level of risk assessment influ-
ences primarily the determination of the
recall frequency and time requirements.
It should also provide a perspective for
the evaluation of risk assessment con-
ducted at the tooth and site level.
At the tooth and tooth site levels, re-
sidual periodontal support, inflamma-
tory parameters and their persistence.
pre.sence of ecological niches with diffi-
cult access such as furcations, and pres-
ence of iatrogenic factors have to be put
into proportion with the patient's over-
all risk profile (Fig. 2). The clinical util-
ity of tooth and site risk assessment re-
lates to rationale allocation of the recall
time available for therapeutic inter-
vention to the sites with higher risk, and
possibly to the selection of different
forms of therapeutic intervention.
Clinical periodontal diagnosis 247
Patient A Patient A
FMBS=7% FMBS=7%
5 residual pockets 5 residual pockets
Patient C
ron smoker non smoker
#11 distal #16 mesial
Blood glucose
150mg/100mL
absence of BOP persistent BOP
Smoker (20/day)
PPD = 4 mm PPD = 6 mm
FMBS=50%
#43 distal
Patient B persistent BOP
Ff^BS=42% PPD = 7 mm
Smoker (20/day)
#21 distal
persistent BOP
PPD = 4 mm
100
Leve! of Risk for Disease Progression
Fi^. 2. Continuous Multiievel Risk Assessment. Subject, tooth and site parameters are com-
bined to establish the clinical risk for disease progression. Please note that different sites in
the same patient may have a different level of risk. Subject based risk factors or markers are
used to put the tooth and/or site risk assessment in perspective.
sofortige Beurteilung des parodontaien Ge-
Acknowledgements sundheitszustandes ernes einzelnen Patienten
Supported in part by Swiss National und erlauben eine Abschatzung des mogli-
Foundation for scientific research grant chen Risikos einer Reinfektion und/oder ei-
nes weiteren Fortschreitem der Erkrankung
32-37763.93 and by the Clinical Re-
im ganzen Gebiss. an einem Zahn oder an
search Foundation for the Promotion einer einzelnen Stelle.
of Oral Helath, University of Berne,
Switzerland.
Resume
Diagnostic parodontal chez les patients paro-
Zusammenfassung
dontaux traites. Powquoi. quand et eomment
Partuhmak' Dlagtwstik in hehandeiren Paro- etjjphver Ics parametres cliniques
donuus-Falk'jiten. Warum, wie und wami nr'f- Le but du diagnostic parodontal chez les
den klhUM'he Parameter augewendcf patients en phase de maintien, est de sur-
Das Ziel der klinischen parodontalen Dia- veiller le risque de progression de la mala-
gnostik bei Patienten in der Betreuungsphase die parodonlale. Ce risque de progression
ist das Aufzeigen von Risikofaktoreti eines devrait etre continuellement surveille au ni-
weiteren Fortschreitens der parodontalen Er- veau de patient, de la dent et du site lors de
krankung. Die Risikofakloren sollte konti- chaque visite de maintien. Chez le patient.
nuierlich bei Jeder Recallsitzung patienten-. 1 influence de tnaldies systemiques. du taba-
zahn- und stellenbezogen erfasst werden. Auf gisme. de sa compliance au programme de
der Ebene des Patienlen sind die Bedeutung maintien. la perte de tissu de soutien en
der systemischen Erkrankungen, das Rau- fonction de son age. la presence de plaque
chen, die Mitarbeit des Patienten wahrend et'ou de saignement ainsi que la prevalence
der Erhaltungsphase, der Verlust von paro- des poches residuelles ,sont d'une importan-
dontalem Stutzgewebe im Verhaltnis zum ce capitale. Au niveau de la dent et du site,
Alter des Patienten, die Plaque- und Gingi- le tissu de soutien parodontal, les paramet-
valindizes und die verbleibenden parodonta- res inflammatoires ei leur persistance, la
len Resttaschen von entscheidender Bedeu- presence de niches ecologiques d'acces dif-
tung. Im Zusammenhang rtiit dem allgemein- ficile, telles que des furcations, et enfin la
en Risikoprofil des Patienten mtissen die presence de facteurs iatrogenes sont a met-
zahn- und stellenbezogenen Parameter wie tre en proportion avec le profil global de
restliches parodontales Attachment. Entzun- risque du patient. Les informations recueil-
dungszeichen und ihr Fortbestehen. das Vor- ties iors de la surveillance clinique et I'eva-
handensein von okologischen Nischen mit er- luation continuelle des risques a tous les ni-
schwertem Zugang. wie z.B. Furkationen. veaux, facilitent I'appreciation immediate de
und die Anwesenheit von iatrogen Faktoren la sante parodontale d un individu et le ris-
gebracht werden. Die durch klinische Unter- que eventuel qu'il eticourt de contracter une
suchungen und standiges Erfassen der Risi- nouvelle infection evou de progression de la
kofaktoren auf den verschiedenen Ebenen maladie. au niveau de la dentition et meme
gewonnenen Informationeii ermoglichen eine d'une dent ou d'un site particulier.
248 Lang & Tonetti
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Vanooteghem, R., Hutchens, L. H., Garrett, Niklaus P. Lang
S., Kiger. R. & Egelberg, J. (1987) Bleed- Department of Periodontology and Fixed
ing on probing and probing depth as indi- Prosthodontics
cators of the response to plaque control University of Bern
and root debridement. Journal of Clinical Friihiirgstrasse 7
Periodontohgv 14, 226-230, CH-3010 Bern
Vanoothegem, R.. Hutchens, L.. Bowers, G.. Switzerland
Kramer. G., Schallhorn, R., Kiger, R..
Crigger, M. & Egelberg, J. (1990) Subjec- Tel.: +41-31-632-2577
tive criteria and probing attachment loss Fax: +41-31-3SI-7H34
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