Periodontology 2000, Vol.
39, 2005, 30–39 Copyright
Blackwell Munksgaard 2005
Printed in the UK. All rights reserved
Clinical parameters: biological
validity and clinical utility
ANDREA MOMBELLI
Periodontal diagnosis and monitoring rely upon
clinical parameters to a large extent. Clinical diag-
nosis directly affects decisions to initiate therapy, to
select methods, and to outline the topographical area
of application. Dentists also evaluate the outcome of
therapy, and attempt long-term prognosis based on
clinical parameters.
This paper will specifically focus on the biologic
validity and utility of clinical parameters assessed
with the periodontal probe.
Biological validity
Pocket formation and loss of attachment are pathog-
nomonic for periodontal disease. The reduction of
periodontal pocket depth and gain of attachment are
thus obvious clinical goals of periodontal therapy, and
pocket probing appears as the evident method for
diagnosing the disease and evaluating therapy. The
primary parameters assessed by periodontal probing
are probing pocket depth (the distance between the
gingival margin and the bottom of the sulcus ⁄ pocket),
gingival recession (the distance between the cemento-
enamel junction and the gingival margin), and clinical
attachment level (the distance between the cemento-
enamel junction and the bottom of the sulcus ⁄ pocket).
Measuring probing depth, recession, and attachment
level at the same time is redundant, since with any two
of these parameters the third is also established
(Fig. 1). Periodontal probing also generates informa-
tion regarding bleeding on probing and suppuration
from the periodontal pocket. In addition, the perio-
dontal probe is commonly used to determine the
roughness of the tooth surface and to detect subgin-
gival calculus. These two aspects are not expressed
numerically. Periodontal probing is site specific;
secondary parameters on the level of the patient can be
generated using data from several sites (e.g. mean
30
PERIODONTOLOGY 2000
probing depth and attachment level, the percentage
of deep periodontal pockets or sites bleeding upon
probing).
What do we measure?
Finding the Ôbottom of the pocketÕ by inserting a
blunt instrument between the tooth and the gums
until it meets resistance seems to be a straight-
forward procedure. Various technical and biological
factors, however, determine how a probe tip advan-
ces and where it finally stops. Up close, this proce-
dure is surprisingly complex, and the data it
generates need some interpretation. Firstly, the shape
and the diameter of the probe matter, as they deter-
mine the pressure of the instrument on ⁄ in the peri-
odontal tissues at any given probing force (47). Probe
design was a discussion topic for a long time (95).
The periodontal probes mostly used today in practice
and clinical research are slightly tapered metal cyl-
inders with horizontal marks, with a rounded tip
0.4–0.5 mm in diameter. These types of probes have
been used in the majority of clinical trials to record
pocket probing depth and clinical attachment level
on a millimeter scale.
To discuss the biological significance of perio-
dontal probing, we need to briefly review the
anatomic structure of the Ôperiodontal pocketÕ and its
histologic components interfering with probe inser-
tion. Under ideal conditions of periodontal health,
the lateral wall of the gingival unit is lined by the
sulcular epithelium in the coronal part and the
junctional epithelium in the apical part. The junc-
tional epithelium tapers apically, and its free surface
lines the bottom of the sulcus in the region of the
cemento-enamel junction. An attachment apparatus
consisting of a basement lamina and hemides-
mosomal junctions, termed epithelial attachment,
provides a union between the epithelium and the

Baseline Month 2 Month 6
0
1.3
1 2.0 Gingival Recession
2.2
4 Probing Pocket Depth
4.4
mm
4.8
5 7.4
6
7 subjects treated with scaling and
2.3 Clinical Attachment Gain
8 1.7
9 (data from 64).
tooth surface (87). With the development of perio-
dontal disease, the epithelium progresses apically
from the cemento-enamel junction to follow the
receding connective fiber attachment. An inflam-
matory infiltrate extends apically and laterally into
the connective tissues. Periodontal therapy reduces
inflammation and gingival swelling and increases the
firmness of the tissues (10). Histologically, a reduc-
tion of the inflammatory infiltrate and the formation
of a new epithelial attachment can be demonstrated
(89).
Several studies have indicated that periodontal
probes easily fail to identify the apical termination of
the junctional epithelium, or the coronal level of the
connective tissue attachment (2, 4, 23, 27, 34, 56, 61,
77, 83, 86, 88). The error by which the probe misses
these histological landmarks is variable. Probe tips
penetrate differently in diseased and healthy pockets
(4, 20, 26, 42, 61, 83, 91). In untreated periodontal
disease, probe tips inserted with a force of 0.5 N
penetrated through the junctional epithelium, and
stopped in the connective tissue, approximately
0.5 mm away (23). In smokers, due to reduced
inflammation, the probe tips seemed to penetrate
less easily and approached nearer to the actual
attachment than in nonsmokers (13). After treatment,
probes tended to stop between the junctional epi-
thelium and the tooth, at a distance of approximately
0.7 mm coronal to its apical termination (23). Thus,
gain of clinical attachment, observed by probing after
treatment, cannot be solely explained by the forma-
tion of new connective tissue attachment to the root
surface. If the aim of periodontal probing were to
locate the apical termination of the junctional epi-
thelium, one would actually have to apply higher
forces for probing after therapy than at an initial
Clinical parameters
Month 12
1.6
4.8
Fig. 1. Gingival recession, probing
depth, and clinical attachment level
gain in deep periodontal pockets of
2.3
root planing and adjunctive sys-
temic antibiotics. 0 mm corresponds
to the cemento-enamel junction
examination (quite the opposite is probably done by
many clinicians).
Apart from biological properties of the periodontal
tissues, the insertion of a periodontal probe may be
influenced by factors which change due to treatment,
but are not the object of the measurement: the
roughness of the root surface, or patient comfort
(tendency to lighter probing if a patient signals dis-
comfort to mechanical irritation).
Reproducibility and longitudinal
monitoring of clinical attachment level
and pocket probing depth
Information about dynamic phenomena may be
gained by combining data from repeated assess-
ments. The potential to record loss or gain of clinical
attachment is limited by the resolution of probing
and depends on the reproducibility of a single
measurement. Probing with a manual probe has a
resolution of 1 mm. Electronic probes have been
proposed that may have a resolution up to 0.2 mm,
making it theoretically possible to detect smaller
changes in probing depth or clinical attachment level
over time (43, 69). Thirty to forty percent of perio-
dontal pockets that are re-probed with a manual
probe after 1–3 weeks may show a positive or neg-
ative deviation in clinical attachment level or probing
depth of ± 1 mm (41, 67). The standard deviation of a
single measurement of an average periodontal pocket
has been reported to be in the range of 0.8–1 mm (1,
7, 33, 62, 73, 74). Consequently, in an existing peri-
odontal defect, true changes in probing depth or
clinical attachment level can hardly be discriminated
from probing error in practice unless they exceed
31
Mombelli
2 mm. Shallow periodontal sites have a narrower
range in probing depths and therefore show better
reproducibility (69). Analytical procedures have been
designed to test for significant changes in clinical
attachment level on the basis of pairs of attachment
level measurements, taken 1 week apart, and repea-
ted at 2-month intervals over 1 year (33). These
procedures have been helpful in clinical research to
test the prognostic capability of simpler means to
detect active disease. One-time assessments of pro-
bing depth, clinical attachment level, bleeding on
probing or suppuration, used alone or in combina-
tion, were unable to indicate a state of activity as
determined by these procedures (32, 33). To improve
reproducibility of probing, especially in untreated
patients where the presence of subgingival calculus
may interfere with probe insertion, it has been sug-
gested to measure each site twice using a Ôdouble-
passÕ method (73, 74).
Probing force and probing depth
Early studies showed that forces used by clinicians for
periodontal probing varied considerably. Forces
differed between examiners, and when different
regions of the mouth were probed (24, 25, 36). Force
controlled probes have been proposed to reduce these
possible sources of error (12, 14, 15, 28, 60, 77, 93, 96).
By recording probe penetration into a periodontal
pocket as a function of probing force (Fig. 2) it can be
demonstrated that probing depth depends upon the
force applied to the instrument (65, 69). Since depth-
force curves have the characteristics of saturation
curves, which flatten with increasing probing force,
small changes of probing force have a greater impact
on the reproducibility of depth readings in the low
force range. In other words, deviations in probing
depth are generally more likely to occur if one uses
light forces (e.g. 0.25 N) for probing than heavier
ones. Thus, if high reproducibility is the primary goal,
one should use a high probing force level.
Comparing depth-force curves recorded before and
after periodontal therapy, it has been found that the
force range chosen for repeated probing influences
the amount of attachment level change determined
(68, 70). As depth-force curves may have different
shapes before and after treatment, the measurable
outcome of a treatment, expressed as the difference
in probing depth and attachment level, depends on
the force chosen for probing. In theory, if the inser-
tion pressure is smaller than the initial resistance of
the marginal tissues, the probe tip will not penetrate
into the sulcus. In this extreme case, the clinically
32
determined attachment level would seem to be
identical with the location of the gingival margin. If
therapy produces shrinkage of the gingival tissues,
the use of such a slight probing force would lead to
the false conclusion that treatment has produced
attachment loss. On the other hand, since scaling and
root planing induce a significant reduction of probing
depth as well, there is a crossover of the depth-force
plots obtained before and after treatment when they
are superimposed. This is illustrated in Fig. 3, where
the mean depth values obtained at 0.25, 0.50, 0.75,
1.00, and 1.25 N are used together with the mean
levels of the gingival margin (intercept with y-axis)
before and after treatment to project depth-force
curves. Crossover is located at about 0.1 N in this
graph (70). Thus, a probing force of 0.1 N would
indicate no change in clinical attachment level.
Even lower forces would indicate mean attachment
loss, and higher forces would indicate attachment
gain. Beyond the crossover area, lighter forces may
yield more attachment gain than higher forces,
because the newly formed long junctional epithelium
may not resist probe penetration at higher probing
forces.
The phenomenon described above appears quite
clearly in the results of a study by Proye et al. (78).
Using standardized probing forces of 0.15, 0.25, and
0.50 N, these authors evaluated the effect of a single
episode of root planing. They reported a mean apical
shift of 0.84 mm of the gingival margin, and found no
attachment level alterations with a probing force of
0.15 N but a significant attachment gain when the
effects of treatment were evaluated at higher force
levels.
Although not all studies have demonstrated signi-
ficant improvements in probing reproducibility
when using force controlled periodontal probes (77,
90, 97), standardization of probing force has been
advocated because it reduces the possibility of
operator bias. A more important source of error may
be probe positioning, which is difficult to standard-
ize under practical conditions (36, 99). Splints have
been used in some trials (41, 98) to secure probe
insertion pathways and to provide vertical reference
points for depth readings. There may be some jus-
tification for the use of these tools in clinical re-
search, but they are too complicated to be useful in
clinical practice.
Bleeding on probing
The characteristics of the gingival tissues associated
with bleeding after probing were investigated histo-
 Clinical parameters

Probing force (N)

0.00 0.25 0.50 0.75 1.00 1.25
0

0.5

1
Probing depth (mm)

1.5

2.5

3.5 Fig. 2. Mean depth force curves

obtained from probing measure-
4 ments with a probing device
recording depth and force simulta-
4.5 neously (data from 69).

Probing force (N)

0.00 0.25 0.50 0.75 1.00 1.25
0

2
Depth (mm)

Fig. 3. Mean depth values obtained

4 at 0.25, 0.50, 0.75, 1.00, and 1.25 N
are used together with the mean
levels of the gingival margin (inter-
5
cept with y-axis) to project mean
depth-force curves. Crossover of the
before and after treatment curves is
located at about 0.1 N (data from
6 70).

logically (30). Specimens from sites bleeding after
probing with 0.25 N showed a significantly increased
percentage of cell-rich and collagen-poor connective
tissue, but no increase of blood vessel lumens.
Experiments in periodontally healthy subjects dem-
onstrate that occasional bleeding upon probing can
occur even in the absence of disease (51). In subjects
with a reduced but healthy periodontium, a nearly
linear relationship has been found between the per-
centage of sites bleeding on probing and probing
force (46). These studies pointed to tissue trauma due
to probing with high force as a possible reason for
bleeding in the absence of disease. Probing with
controlled forces not exceeding 0.25 N was thus
recommended. Controlled forces were recommended
already in earlier studies to increase the reproduci-
bility of bleeding on probing, but at a much higher
force of 0.75 N (90). It is quite obvious that the
reproducibility of bleeding on probing can be
improved by either increasing or lowering the
probing force level (eventually, either all, or no, sites
will bleed reproducibly).

33
Mombelli
Clinical utility
The utility of a diagnostic parameter depends on its
ability to answer a concrete diagnostic question and
on the clinical context in which this question is
asked. Diagnostic tasks in periodontics may include
the identification of people and dental sites at risk of
developing periodontitis, the detection of early stage
disease in apparently asymptomatic individuals, the
classification of disease categories, the delineation
and local assessment of the disease in affected sub-
jects, the prediction of the likely response to a spe-
cific therapy, monitoring of treatment efficacy, and
finding recurrent disease. The utility of a diagnostic
parameter may not be the same in every one of these
situations – it therefore needs to be determined
separately each time. For example, if a parameter has
been confirmed to indicate a risk for further attach-
ment loss in previously treated subjects, it is not
automatically a proven useful diagnostic tool to
detect early stage disease in a large population.
Risk assessment and screening
The issue of periodontal risk factors has been dis-
cussed in detail in recent years. Risk factors may
influence a subject in general, or may affect perio-
dontal tissues locally (for review, see 81). Individual
variability in periodontal tissue destruction, docu-
mented longitudinally in untreated populations (59),
calls for diagnostic procedures for the early identifi-
cation of subjects at high risk for severe periodontal
disease. While the paramount roles of smoking and
systemic diseases, notably diabetes, have been clearly
17
16
15
14
13
12
11
41
42
43
44
45
46
47
10 8 6 4 2
Probing pocket depth (mm)
Fig. 4. Symmetrical behavior of tooth-specific mean probing depths in one subject (data from [66]).
34
established on the subject level, much less is known
about specific local factors.
Monitoring untreated disease by recording pocket
probing depth, clinical attachment level, or bleeding
on probing has a limited value for indicating present
activity or predict future attachment loss (32, 33, 35).
However, in a population of elderly subjects, teeth
with reduced attachment levels had an increased
probability of being lost during the next 5 years. In
addition, teeth that actively lost attachment during
an observation period were more likely to be lost
during the following period than were teeth with a
stable clinical attachment level in the first period
(11). As it is characteristic for periodontal disease that
not all parts of the dentition are affected with equal
severity, is it thus indispensable to monitor all sites
regularly? The answer to this question would be
affirmative if the distribution and temporal occur-
rence of periodontal lesions were entirely random. If
the distribution and occurrence is, however, struc-
tured, a limited assessment in certain areas, and at
specific time points, may be sufficient to obtain
diagnostically useful information. Using data from
comprehensive assessments in the entire dentition,
we estimated the influence of symmetry on the
variance of clinical and microbiological parameters
in 56 patients with chronic periodontitis (66). The
impact of contralateral conditions was determined
on the level of the site, the tooth (Fig. 4), and the
quadrant. Significant correlations were detected in
probing depth, recession, clinical attachment level,
total cultivable bacterial counts, and the plaque
index, recorded on the right and left side on all levels
of analysis. Given this amphichiral nature, the diag-
nostic advantage of full mouth recordings over partial
27
26
25
24
23
22
21
31
32
33
34
35
36
37
0 2 4 6 8 10

assessments should be evaluated carefully in various
clinical situations. Correlations other than symmetry
should also be explored for their potential to improve
the utility of clinical (and other) parameters.
Attention has been focused in the past on the
possibility that periodontal disease may not be a
continuous process, but may be characterized by
episodes of activity, followed by periods of relative
quiescence. As has been discussed above, the
potential of detecting an active episode of perio-
dontitis by simply probing a previously measured site
after a few weeks or months is limited. On the other
hand, the true impact of short bursts of activity on
the accumulated loss of periodontal tissues over time
also remains to be determined, and may have been
overestimated (31, 80). Slow continuous attachment
loss may have considerable consequences in the
long run, although it is undetectable in studies lim-
ited to a few months’ duration. Given the inaccuracy
of periodontal probing, the detection of a continuous
disease process leading to 6 mm attachment loss
over 60 years would require a minimal study period
of 20 years (subsequent measurements must yield a
difference of at least 2 mm in order to distinguish
tissue destruction from measurement error with
sufficient confidence).
Classification and treatment planning
The historical perspective and potential problems
with the current classification are discussed in a
broader context by van der Velden in this volume
(92). The present chapter confines itself to a discus-
sion of the impact of clinical parameters on the
classification process. Eight classes of periodontal
diseases and conditions are currently distinguished.
Among them are chronic periodontitis, aggressive
periodontitis, and periodontitis as a manifestation of
systemic diseases (3). Although these three forms are
all associated with an increased probing depth and
clinical attachment level, their differentiation is not
based on criteria derived from the periodontal pocket
chart. The diagnostic key elements include the
patient’s age, systemic health, and the occurrence of
similar problems in the family – information essen-
tially obtained by assessing the medical and dental
history.
The clinical periodontal examination thus does not
classify causes, it classifies destruction patterns. A
major limitation of periodontal probing is its inability
to distinguish previous tissue loss from current
disease activity. Clinical attachment level and pocket
probing depth reflect the extent of prior, but not
Clinical parameters
necessarily current, disease. Since periodontal tissue
damage accumulates over time, the disease may
appear more severe in elderly patients than in young
ones, although in terms of disease progression, the
contrary may be the case. For a further discussion of
this, the reader is referred to the article of Hujoel in
this volume (40).
Decades of clinical experience and well documen-
ted longitudinal studies have shown that all clinically
distinguishable forms of periodontal disease respond
favorably to a nonspecific reduction of the subgin-
gival bacterial mass (52, 53, 71, 72, 75, 84, 85). How-
ever, studies have also indicated that certain
circumstances, identifiable by periodontal probing,
may justify specific forms of therapy.
• Calculus removal is accomplished less often in
deeper periodontal pockets (19, 79). Calculus
removal in deep pockets has been found to be
more efficient if a surgical access is provided for
root instrumentation (16, 18, 19).
• Deep periodontal pockets showed more pocket
reduction following surgical procedures (54, 55, 75,
76).
• Sites with shallow initial probing depth have a
tendency to lose attachment (8, 54).
• In patients with deep periodontal pockets, sys-
temic antibiotics in conjunction with scaling and
root planing can be of additional benefit compared
with scaling and root planing alone (38).
Monitoring
The paramount question when evaluating the success
of periodontal therapy is whether further interven-
tions are necessary or whether the therapeutic phase
can be concluded. In general, this decision is based on
a comparison of clinical attachment level, probing
depth, and radiographs taken before and after treat-
ment. This means that the prognosis for future tissue
changes is based on clinically observed reactions
appearing as a result of treatment. Monitoring of 1688
sites in 49 patients over 24 months indicated that the
outcome of nonsurgical therapy in proximal surfaces
of nonmolar teeth was not compromised by the
severity of the initial soft tissue or bony lesion (9). The
value of clinical and microbiological data assessed
shortly after the completion of nonsurgical perio-
dontal therapy to predict the outcome several months
later is limited (17, 22). The key parameters of probing
depth and clinical attachment level may continue to
improve over a period of 6 months (45). It would be
desirable to have a set of parameters for an early
evaluation of treatment success in order to be able to
35
Mombelli
decide rapidly whether additional or alternative
therapy is necessary.
Longitudinal studies on successfully treated
patients show that the results of conventional peri-
odontal treatment can be maintained over many
years if an efficient recall system is provided (5, 6,
48, 53, 57, 85). In well-maintained populations,
recurrent disease seems to be limited to a few
individuals. In these subjects, however, several sites
are often affected at the same time (29, 39, 63).
Clearly, these individuals need to be identified early
on. Very tight recall systems require an expensive
work force and are a nuisance to the patients, not to
mention the tissue damage caused by repeated
instrumentation. This indicates a need for diagnostic
tools to select the optimal recall interval for each
patient individually and to decide which sites need
retreatment in excess of what regular prophylaxis
implies. Clinical indices assessed during the main-
tenance phase are poor prognosticators of attach-
ment loss (44, 50, 94). In one study (49), 41 patients
were monitored after periodontal therapy for
bleeding on probing for 2 1 ⁄ 2 years in a mainten-
ance program. The sensitivity of frequent bleeding
to predict clinical attachment loss > 1 mm was only
29%, and the specificity 88%. On the other hand,
continuous absence of bleeding on probing had a
predictive value of 98% for stability. Using the
methodology of the systematic review an attempt
was made to assess the predictive value of residual
probing depth, bleeding on probing, and furcation
involvement in determining further loss of attach-
ment following initial cause related therapy (82).
After a detailed review of 47 publications, only one
study fulfilled all inclusion criteria. That study (21)
included 16 subjects reviewed over 42 months and
demonstrated that residual probing depth was pre-
dictive of further disease progression, whereas per-
sisting bleeding on probing was not.
Conclusions
Reduction of pocket probing depth and clinical
attachment level gain are the obvious clinical goals of
periodontal therapy. Gain of clinical attachment is
largely due to increased tissue firmness and epithelial
attachment, and cannot be explained solely by the
formation of new connective tissue attachment. If the
aim of periodontal probing were to locate the apical
termination of the junctional epithelium, one would
actually have to apply higher forces for probing after
therapy than at an initial examination.
36
Certain circumstances, identifiable by periodontal
probing, may justify specific forms of therapy. Teeth
with reduced attachment or with evidence of having
actively lost attachment recently are at greater risk of
being lost. In deep pockets, calculus removal is more
efficient after surgical access and systemic antibiotics
can offer an additional benefit. Furthermore, residual
probing depth is predictive of future disease pro-
gression.
Since the distribution and temporal occurrence of
periodontal disease is not entirely random, a limited
assessment of clinical parameters in certain areas,
and at specific time points, may be sufficient to obtain
diagnostically useful information in many situations.
Correlations between parameters (37, 58) should be
explored to reduce redundancy and improve the
utility of multiple or repeated measurements.
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