This is the Perio Hygienist Podcast – a podcast centered on the intersection between the specialty of periodontics and the profession of dental hygiene. My name is Dr. Ben Young.
In this installment, we will think about Periodontal Probing in Real Life.
We all know what it’s like to have to do an examination on someone that has the potential of causing some pain. And we are also very aware that each person’s pain threshold is unique to them. Some tolerate the procedure well and others have more difficulty.
Periodontal probing fits this description.
It can be especially difficult in untreated periodontal cases because inflamed tissues hurt more. And the patient may be bringing this memory with them into their appointment with you for supportive periodontal therapy.
Certainly, for you, we are not talking about untreated patients so tenderness should be improved. But still, for this discussion let’s imagine that you plan to take pocket measurements on this patient for the first time.
The purpose for today’s podcast is to give you tips on how to make this run smoothly and to reduce your stress levels in the process.
If you are listening to this and have not yet been instructed on how to perform this examination, this may be a little premature.
On the other hand, if you have any experience in this area, then think of me like, say, your tennis coach. You know the fundamentals of the game and now I want to give you some tips that will hopefully improve both your performance and provide you some peace of mind.
To do this, we will go over some background, but with the assumption that this is not the first time you have heard a lot of this.
What I want to do is dispel some ideas that most people have about periodontal probing that keeps them from actually enjoying this step. You heard me right. This step should be easy to perform, and I find it interesting because it is an opportunity to really study and try to clearly understand the conditions of someone’s mouth. It’s an up-close examination and provides a great deal more information than simply a collection of numbers on a chart.
So let’s get started.
First, and this is returning to the previous four podcasts, never probe a stranger. Find out how treatment has been thus far. Find out if they have any concerns about probing. And do they understand why it is necessary?
If, on the outside chance, they don’t know why it is important, then they are not really complying with periodontal therapy. They are just putting up with it. If they have this attitude, then probing is something you will be doing to them rather than something you are doing for them in order to provide them with the information they need to know as to how best to manage their periodontal conditions.
Do you get how important all of this is to you? If you are performing a task that may cause some discomfort because they want you to, it makes all the difference as to how this appointment will go. Without this understanding, which honestly takes effort on our part to engage them first at the adult human being level, then the default which might be a lot of fears the patient has walked in with will create a subtle tension unhelpful to everyone involved.
So that’s tip number one. Establish rapport and obtain permission to accomplish this procedure.
My second tip is that this periodontal probe examination and documentation is the key to managing periodontal care. This is because the problems you are looking to address are not visible to you intraorally. And radiographs are useful to see some areas of the mouth, but not others, and they aren’t as accurate as probing measurements. Don’t be distracted by calculus and stain. These are not the problem, nor are they even the cause of the problem.
This is why supportive periodontal therapy or periodontal maintenance is not just a glorified prophy.
Tip number three is be gentle. If you are, then you will usually not need to use topical anesthetics to probe. I never use topical anesthetics to probe. Ever.
Now here is the concern that most people have about probing pressure. What if they don’t go all the way down to the bottom of the pocket?
Let me ask you a question. Is it a good thing to go down into the pocket at some arbitrary pressure that will detach the junctional epithelium that has tightened and attached to the root following active therapy?
I don’t think so. I use the weight of the probe without additional pressure applied. I might wiggle the probe delicately in order to make sure that I’m in the pocket, but if it goes nowhere, then the pocket is shallow in my book.
And what if I’m wrong? Well that’s the beauty of repeat measurements. Miss something this time and you will likely pick it up next time. The accumulation of data adds to the comfort level that your probing measurements are accurate. Relax. Stop worrying.
So, why did we all think that we had to apply heavier pressures? Why did we have to use electronic postage scales to standardize probing pressures in school? Or why did we use pressure sensitive probes like Florida probes thinking that this would give us better data?
The answer is Science.
What do I mean?
Much of what we know about periodontal disease comes from periodontal probing data.
These studies involved a lot of subjects and a lot of examiners. In order to assure that the data was as accurate as possible, it was important, and still is, that all examiners be calibrated. This means they all need to use the same type of probe and they all have to come to agreement as to how they will read measurements, where they will measure around the tooth or teeth, how much angle relative to root surfaces is acceptable and how much pressure will be applied.
In this situation, a heavier pressure is more reproduceable. Anyone who has been involved with research of this nature, whether as an examiner or a patient, will tell you the probing is uncomfortable.
Well out of these studies we have learned a number of things.
First, we know that inter-examiner error is a bigger problem compared with intra-examiner error. This is to say that errors between two examiners – inter-examiner – is greater than errors caused by the same examiner during two examination accomplished at different times – intra-examiner. So in the studies you might read you will see that many use only one examiner to accomplish the measurements and that this individual is not involved with the therapeutic side of the study. In other words, the examiner is blinded to knowing which side of someone’s mouth received a certain type of treatment and which side received something else.
So what does this have to do with you? Simply this, it is more important that your measurements agree with your previous measurements than that they agree with my measurements. It is more important that you obtain your own measurements than that you confirm that my measurements are right or wrong.
And do you know what you will find? That your measurements will be plus or minus one millimeter from my measurements. In other words, the chances that you will probe two, three or more millimeters apart from my measurements as an error is remote and that if you do encounter a dramatic change, something has occurred that needs to be evaluated further.
And if you send a patient back to see me, do you know what I will do? Of course you know. I will remeasure for myself. It’s no big deal. That’s the point. It’s the accumulation of data that creates the safety net for the patient.
Here’s something else we know from probing studies. The probe tip when measuring someone with yet-untreated periodontitis will be in the connective tissue this means beyond the base of the true pocket. And the probe tip, when measuring someone who has been treated for periodontitis so there is no longer any significant inflammation in the area, will be positioned coronal to the true pocket attachment. This difference in before and after probing depths is in the range of two millimeters. This is why we can say that we can anticipate up to two millimeters reduction from scaling and root planing. Now please do not misunderstand what I am saying. I am not saying that everything will shrink two millimeters following scaling and root planing. I am saying we can see this. It’s useful to know.
But what about those times when a pocket changed six or seven millimeters following scaling and root planing. This may have been in an area of a periodontal abscess where the tip of the probe initially was in the soft tissues but not against the root. When this healed the probe returned to simply measuring the pocket.
So to review:
Tip Number One: Never perform periodontal probing on a stranger.
Tip Number Two: Understand that the periodontal probing examination is the key to managing supportive periodontal therapy.
Tip Number Three: It’s okay to be gentle because it is your repeat measurements that provide the important data needed to manage the patient’s periodontal therapy protocol.
Now Tip Number Four: Eliminate zeros and ones.
Periodontal pocket numbers are arbitrary statements that tell us the pocket is no deeper than the number measured.
This means that zero is not a measurement in this system because the number one includes it. Zero provides no useful information.
But the measurement of one millimeter provides no useful clinical information either.
So let me stop and remind us again that this is different from scientific measurements where we actually attempt to measure more accurately than even one millimeter. We are not seeking and do not need more accurate measurements clinically. We need measurements that will help us make decisions as to how to manage the patient.
So what I am saying is that there is no difference between a one millimeter and a two millimeter pocket in terms of periodontal health. Any measurement in this range is considered healthy or stable. Call them all two’s and save your brain some unnecessary mental activity.
What about a two millimeter and a three millimeter pocket?
Well three millimeters in certain areas of the mouth may indicate a problem, so I do differentiate between them.
Tip Number Five: Standardize your probe. Don’t use different types just because there is a box in the back of old probes. I like the UNC probe with 1 millimeter lines and a band between 5-6, 10-11 and 15-16. – but pick your flavor and stick with it.
Tip Number Six: Use magnification and good lighting to accomplish this examination. I use 2.5 X magnification with a center light. Also, I like having patients wear dark glasses during the examination and also while in treatment. This is more comfortable and provides an important level of safety during treatment.
Tip Number Seven: Computerize your data if at all possible. It is the changes in probing depths over time that help us detect problems early and efficiently. Also computer printouts are easy to show to patients. We want patients actively involved in the management of their care. They need feedback on probing depths, probing depth changes and bleeding index.
That’s it for this podcast. We didn’t talk about recession, or bleeding from probing, so let’s get into these areas next time.
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Thanks for listening.
Seven Periodontal Probing Tips
- Obtain permission and buy-in before starting this examination.
- Don’t bypass this procedure because it is the key to managing supportive periodontal therapy.
- Be gentle. Use the weight of the instrument only. And relax, accuracy comes over time with repeat measurements.
- Eliminate zeros and ones.
- Standardize your probe. Don’t use different types.
- Use magnification and good lighting.
- Computerize your data to simplify record keeping and patient feedback.
