Periodontal Probing:ProbeTip Diameter*

Jerry J. Garnick and Lee Silverstein Background: Periodontalprobing is one of the most common methods used in diagnosing periodontal disease-The purpose of this studg was to determine the Importance of the diameter of periodontal probing tips in diagnosing and eualuating periodontal disease. Nlethods: The literature discussing periodontal probe diameters in human, dog, and monkeg studies was reuiewed and compared. Tip diameters uaried from 0.4 to ouer 1.0 mm in these studies. Probe adoancement between the gingiua and the tooth is determined bg the pressure exerted on the gingiual trssuesand resistancefrom the healthg or inflamed trssue. The pressure is directLg proportionate to the force on the probe and inuerselgproportionate to the probe tip diameter. The larger probing diameters reduced probe aduancement into inflamed connectiue tissue. This effect of change tn probe diameter reduced the pressure in a greater manner than an increase of similar change in probe force. Results.' ln the studies reuiewed, the pressure used to place the probe tip at the base of the periodontaL sulcus/pocket was approximatelg 50 N/cm2 and at the base of the junctional epithelium, 200 N/cm2. A needed to reach the base tip dtameter of 0.6 mm LDas of the pocket. Clinical infLammation did not necessari"Lg reflect the seueritg of histological inflammatton, and the recordings mag not illustrate probing depth. Furthermore, probing depth did not identifg anatomical locations at the base of the pocket. Conclusions: Probe tips need to haue a diameter of 0.6 mm and a 0.20 gram force (50 N/cm2) to obtain a pressure which demonstratesapproximateprobing depth. This pressure uas needed to measure the reduction of clinical probing depth, which included formation of a long junctional epithelium as a resuLt of therapg. In addition, different forces or diameter tips are needed to measure healthg or inflamed histological periodontal probing depths. J Periodontol 2000:71:96103. KEY WORD$ Periodontalprobes; dental instruments; periodontal diseases/diagnosis. In diagnosing and evaluating treatment of periodontal diseases, the presenceof inflammation and subsequent pathologic changes of the periodontium are evaluated by various means, including inflammation, presenceof bacteria,gingivalcrevicularfluid flow, and periodontalprobing.These methods demonstrate a lack of sensitivity and objectivity to be totally reliable criteria for clinicians.As a result, there has been researchinterest in these methods with the goal of improving the ability to evaluateperiodontaldiseases.Clinicianscan estimatethe severityof inflammation and morphologicalchanges caused by past periodontal disease but are not able to determine ongoing and potentialtissue destructionusing exist1'2 ing diagnostictechniques. Currently,periodontalprobing depth (PD), loss of connectivetissueattachment,and bleedingon probing are generallyused to estimateseverityof inflammation and responseto treatment.Evaluationof these parametersdepends on the use of the periodontal probe. Therefore, there has been considerable researchinterestin the mechanics and functions of the probe in order to improve its effect. A brief description of periodontal probing is important for this review. The periodontist places the probe into the sulcus or clinical pocket and applies a force to move it apically into the tissue along the tooth surface. The clinician applies pressure on the tissue and when the tissue exerts an opposite equal pressureto the probe, displacement of the probe into the tissue will cease. The pressure exerted by the probe is directly proportionalto the force on the probe and inverselyproportionalto the area at the probe tip (pressure= Force applied on the probe/areaat the tip end =F/pr2 =Fllt(d/2)2; r = radius, d : diameter). With a round probe, a change in the tip diameter has a greater effect on pressurethan does a similar change in the force. An increasein the probing force will increasethe pressure by a proportional amount. However,a relatively similar increase of the probe diameter will reduce the pressureby a proportional amount which is squared. If the force is doubled (20 to 40 gram force), the pressureis increasedby a factor of 2. lf the diameteris doubled (0.4 to 0.8 mm), the pressure is reduced by a factor of 4. It, therefore, is important that in discussionson the use of a peri-

* School of Dentistry, Medical College of Georgia, Augusta, GA.

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Marini, Checchi, Vecchiet,

30. Gillam DG, Bulman JS, Jackson RJ, Newman HN. Comparison of 2 desensitizingdentifricies with a commercially available fluoride dentifrice in alleviating cervical dentine sensitivity.J Peri.odontol 1996;67:737-742. 31. Blomlof J, Jansson L, Blomlof L, Lindskog S. Root surface etching at neutral pH promotes periodontolhealing. J CItn Periodontol1,996:23:50-55. 32. Ingram G, Nash PF. A mechanism for the anticaries action of fluoride.CarlesRes1980;14:298-303. 33. Ten Cate JM, FeatherstoneJDB. Physico-chemical aspectsof fluoride-enamelinteractions.ln: FejerskovO, Ekstrand J, Aburt B, eds. Fluoride in Dentistrg. Copenhagen: Munksgaard; 1996:252-272. 34. Fejerskov O, Johnson NW, Silverstone Liv\. The ultrastructure of fluorosed human dental enamel. Scand J Dent Res 1974;82:357-372. 35. Fejerskov O, Josephsen K, Joost Larsen M, Thylstrup A. Cytological feature of rat ameloblastsfollowing longterm fluorideexposure.CariesRes1980;14:181-182.

Send reprint requests to: Dr. Ida Marini, Via Sant'Angela Merici 60, 25723 Brescia, Italy. Accepted for publication June 2, 1999.

95

the diagnostic chart. He used a medium-thickness silver abscessprobe or a scaler,with a blunt blade. In the late 1950s,Goldmanet aI.,9Orban et a|.,10 and Glickmanll publishedtheir texts on periodontal diseases.All authors agreed on the importance of the periodontal probe in diagnosis, prognosis, and treatment and supported use of the Williams probe which was rod-shaped with 7, 2, 3, 5, 7, B, and 9 mm markings, and a 1.0 mm diameter at the tip.i5't6 Goldman et al.e stated that "Clinical probing with suitable periodontalinstrumentssuch as the Williams calibratedprobe is a prime necessityin delineating the depth, topography and character of the periodontal pocket." Glickmanl l stated that "The pocket probe is an instrumentwith a tapered rod-like blade which has a blunt and roundedtip." These two clasEARLY PERIODONTALPROBE DESIGNS sic publications emphasized use of the probe and the Observationsof clinical inflammationof the gingiva not its configuration;furthermore, the diameter or force was not consideredimportant. Probingwas conand bone loss in radiographshave been used for many years for the diagnosisand treatmentof perisidered to measure the depth of the "histological pocket." In odontal diseases. 1915, Black statedthat flat periodontal probes, 15 mm long with markings every During this period, the rationalefor using a perimm, should be used in examinationof clinical pockodontalprobe became acceptedas part of the exam1t't ets presentin periodontaldiseaseand beforesurgery.3 ination for periodontaldiseases.lT'18 addition, the parameters for the periodontal probe as presented He recommended that the level of the pocket fluid on the probe tip be read to determinethe clinicalpocket by Ramfjordin 19594became acceptedas the norm. depth. Probes were used at baseline examinations However,there was little researchsupporting these parameters.Tibbetts indicated that determination of and before surgery. He did not recommend a probe PD in exact millimeter measurements was importip diameter or probing force. Among the probeshe reviewedwere the MerThe probes most commonly used today were tant.19 developedby Ramfjordin 1959.4He stated that the ritt, Williams, Michigan, and Gilmore (round) and probes in use at that time were too thick to probe Goldman-Fox, Drellich, and Nabers (rectangular). narrow clinical pockets and designeda round probe Neitherthe Merritt or Gilmore probes are calibrated. with a tip diameter of 0.4 mm. This diameter of the The University of Michigan probe had 3, 6, and B periodontalprobe was acceptedas the standard. mm calibrations; the Drellich probe had 4,6, B, and Before Ramfiord's publication, investigators were 10 mm markings; and the Williams, Goldman-Fox, divided regardingthe value of periodontalprobes in and Nabor probeswere marked in 1 mm increments the examination, diagnosis,and prognosis of periwith 4 mm and 6 mm deleted to facilitate reading. odontal diseases.Between 1915 and 1958, several Again, the diameters of the round tip probes were reports supported use of the periodontal probe to not emphasized. 1967, Clavind and Loe reported In determine the diseasestatus of gingival tissues.5-11 the resultsof a researchprotocol in which they used Probespecifications, includingthe tip diameter,were a periodontalprobe tip that was 0.8 mm in diameter generally not indicated, nor was there any research with a 10 gram force.2o on the effect of probe design in most of these reports. Others did not support the use of periodontalprobMeasure of Clinical Pockets bg Probing ing, but rather supported radiographs in the diagnoThe general interpretation of periodontal probing is sis of the periodontaldiseases.l2-14 that the probe measuredthe pocket depth, which was similar to the histologicaldepth. Therefore,by docSimonton5 proposed flat probes 1 mm wide, 10 umenting the amount of displacement of the probe mm long, and notched every 2 mm. Box6 used special gold or silver probes that had 5 different anguinto the tissues, changes in probing depth could be lations. Miller/ suggesteciprobing of all pockets and measured. Ramfjorda suggested the use of a modirecording their depth and putting this information on fied Williams probe, with a diameterof 0.4 mm, which

odontal probe, both the force and the probe diameter (or pressure in N/cm2) are examined in order to reach valid judgments and comparisons. With tissue inflammation, resistance to the probe is reduced so that the probe with the same pressure will penetrate deeper into the tissue until a similar opposing tissue pressureis reached. lf the clinician uses a probe tip with a reduced diameter,the pressure will increase and the probe tip will penetrate much deeper into the same inflamed tissue. Because of the great effect on probing displacement, variationsin probe diameter are important. The purpose of this report is to review the literature on probe diametersand discusstheir importancein the use of periodontalprobing.

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could measurenarrow pockets, rather than the original 1.0 mm. The effectsof this cross-sectional modification on probe penetrationwere not studied. However,publishedreports demonstrated the difficulty of measuring the histological pocket depth. In 1960, Kohler and Ramfjord reported that the sharp end of a No. 2 silver point (0.2 mm diameter) was utilized to measure tissue changes, and probed deeper in areas of anesthesia.2lThe sharp pointed probe was not recommended for measuring PD, and it was recommendedthat PD should be measured before anesthesia was induced. At this same time, 3 reports22-24 demonstratedthat 0.1 to 0.5 mm thick steel bladesor celluloseacetatestrips penetrated beyond the base of the sulcus and into placed a celluthe junctional epithelium. Zander23 lose acetatefilm 0.1 mm thick into the sulcus of a young dog, with a very slight amount of force. The photomicrographsdemonstratedthe location of the strip outside and within the junctional epithelium. The strip was still wider than the junctionalepithelium; therefore,resistancewas by collagen fibers. The strip endedjust coronal to the base of the junctional epithelium. In one part of their dog study, Orban et a1.24 used a steel blade, 0.5 mm thick and 1 mm wide. With a light force they could probe 1 mm deep; with an increased force they could probe 1.5 mm. The probe was slightly apical to the sulcus but still adjacent to the junctional epithelium. Again, this blade was wider than the junctional epithelium. The result, however, also indicated that probing for histological pocket depth was difficult and that using thin probes results in excessive probing. Probingdepth measuredboth the histologicalsulcus/ pocket and the junctional epithelium.The junctional epithelium was 15 to 30 layers thick; each cell is approximately6 pm or 0.006 mm wide,25 which computes to a thicknessof 0.09 to 0.18 mm. This width is too narrow even for the thin Michigan periodontal probe (0.4 mm) to penetrate without involving the adjacent connective tissue. In general, these studies indicated that probing performed with thin probes (0.1 to 0.5 mm) over-probedthe sulcus and extended to the base of the junctional epithelium, and that the connective tissue adjacent to the sulcus wall was a major factor in probe resistance.Therefore, the probing instrument did not measure morphologic identifying locations, such as the base of the histological pocket and junctional epithelium, but measured generaltissue resistanceto the pressureplaced on the probing instrument. Thus the factors involved

in pressure become important in the understanding of probing. These results were supported by studies in dogs and humans using periodontalprobes.Sivertsonand Burgett found that the thin Marquis (Hiatt) probe tip (0.4 mm diameter) extended to the coronal most attachmentand through the junctional epithelium.26 lt Other studiesreportedsimilar results.27,28must be realizedthat even though forces used were low, pressures exerted by the probe were very high because thin probes were used; and penetrationof tissueswas deep. RETATIONSHIP OF PROBE PRESSURE, FORCE, PIAMMTMR, INGIVAL MORPHOLOGY, ffi ANN INFLAMMATIONTO PROBE DISFLACEMENT Listgarten summarizedthe published results by stating that "probing depth measuredfrom the gingival margin seldom correspondedto histologicalsulcus or pocket depth. The discrepancy was less in the absenceof inflammatory changes and increasedwith increasingdegreesof inflammation.Followingtreatment, decreasedprobing depth measurementsmay be due in part to decreased penetrability of the gingival tissues."2e The location of the probe tip depends on the pressureapplied and resistance the tissue. of The probe has greater penetration of tissues with increasing pressureon the probe, and the resistance varied dependingon tissuecharacteristics, morphology, andlor tissue inflammation. In general, the use of the periodontal probe resulted in over-probing of the histologicalpocket or sulcus. van der Velden and Jansen described the different parameters associated with probe movement. They indicated that the pressureapplied to the probe moved the probe along the tooth until an opposing pressurepreventsfurther movement.30 The pressure was equal to force/area at the end of the probe tip and is stated in terms of N/cm2. If the diameter of the probe tip is standardized, such as 0.6 mm, the change in pressure will be directly proportional to the change in force applied on the probe. The displacement of the probe will then depend on the force on the probe and the tissue resistance.3l Typical force-displacementcurves can then be generated (Fig. 1). Inflammationreducesthe ability of the tissues to exert pressureopposing that exerted by the probe, resulting in greater tissue penetration (Fig. 2). van der Veldenand Jansen further suggestedthat with a probe 0.63 mm in diameter, the optimal force to probe the most coronal connectivetissue attachment was 0.75 N; i.e., about 240 N/cmz. Polson et

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Mean Probe Advancement by Force Gontrol lor Sites

Figure l, curves exomplesforce-displocement ot 2 of Groph demonstroting probe diometer probrngs o su/cus o dogThe lnto of tip subsequent probe were into os wos mm.The odvonced thesu/cus forces 0.6 ttssue but wos wlth increosed,movement reduced lncrecsed between 2 the Ihere no drff?rences reslstonce, were stotlsticd/ probing 46; (after reference reproduced ouempts Keagle et ol.; JG withpermission).

2.0

a1.32demonstrated in humans that the periodontal probe penetratedto the base of the junctional epitheq, lium in periodontal health using 205 N/cm2. Both = 1.5 IE pressures would reach the connectivetissue attachE ment and not measure the formation of long junc6' tional epithelium. Garnick et aI.31estimated that !t ct pressureof 47 N/cm2 lforce of 0.2 N, diameter 0.6 o1.0 mm) appliedto the probe placed the tip slightly apical to the coronal edge of the junctional epithelium in healthy tissues (Fig. 3). Tissue pressure that resists probe displacement depends on tissue morphology including loss of attachmentand the severity of tissue inflammation. Clinical inflammationdoes not necessarilycorrespond to tissue inflammation (Fig. 4); i.e., obvious clinical gingival inflammation may not be as severe as with histologicalinflammation.Since histologicalinflammation affects tissue resistance, the clinician may not recognizethe level of tissue resistanceto the probe. Systemic and random errors occur in periodontal probing (see reference 28 for review); this paper addresses random error. There are 4 different variablesconcernedwith probing, 3 of which (force,tip diameter,and probe location) can be standardized,but it is difficult to standardize the fourth, connective "s 1234 5 6 7 8 9 tissue inflammation, since it is (No. Displocemenf x .356=mm displocement) usually evaluated clinically. Standardized probing force, tip gi ol L ,M,N p mo x i l l o ry e o l fh y foched ngi vo h diameter,and probe location can q Q,R ,S o l v e o l o m u c o s o r improve calibration.In practice, m ox illor y inf lom e do f l o c h e d g i n g i v o H,l,J probe location is not standardized because of the need to Flgure 2. locate the most severe areas of with chonge tissueconsistency in curves Groph demonstroting chcngesin the force-displocement (heolthyversus inflomedottoched (ottochedgngiva versus mucoso)ond with inflommatton olveolor disease for treatment. However, gtngvo) in the dog. Both fodors resultedin force-displocement curves shifiingto the righg in researchprotocols, location is in t.e,, greotertlssuepenetrotion the someforceond probetip diometerot 0.6 mm, with chonges at in standardized order to evaluate type of tissue ond inflommotion. change of diseaseat one site.
c ot

2000 J Periodontol. January

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B Figure3. Regresslon ofdoto onolysis curves from force-displocement of

probtng gngvolsulcus dogs.The probe wosestimoted the of tip ta be otthe bcse ofthesuicus pressures47 Nlcmz wrh of ft74 kPo) tn (A) ondot themost-coranol connective ottochme witho tlssue nt pressure 298 Nlcmt(1927kPo) (B).This of in demonstroted thot pressures different resulted different penetrotion tn degrees oftlssue (ofterCornick et ol.; reprence l). 3 lJ

Figure 4" Crophs demonstroting developmentclinical gngval the of tnflommotion dogs ond results (A) in when gingivci the tlssues were (B). ginglvol evoluoted histologicolly Ainicol inflommoLion wos chorocterizedgngivol by tndex gtngvol flow. ond Histologcol fluid greot voriottons especiolly in situotions heolthy slighdy were of ond (Gl inflomed = 2) gngva(ofterGornick et ol.; refbrencel). 3 lJ

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Tabl e l .

Comparison of Probe Tip Diameters and Force in PeriodontalProbings

Estimated Force ProbeDiameters for to Measure Histological Sites Diameters (mm) 0,4 05 Base Sulcus of (P= 50 N/cm2) 6gr(006N ) l 4 gr (0. 4 N )x l
Coronal Connective Tissueattachment (P = 7OO N/cm2)

2sgr (0.2s | N) N) 57gr (0.57

Best combinations of force and probe diameters are: * 0.6 m m di am eter at 20 gr am for c e ( l eas t for c e i n a h a n d -h e l d p ro b e ) t o pr obe the bas e of the s ul c us and deter m i ne for m at i o n o f l o n g j u n c t i o n a l eD i thel i um . f 0.4 mm diameter at 20 lo 25 gram force to probe to connective tissue attachment to determine regeneration of connective tissues but not long j unc ti onal epi thel i um for m ati on. With use of a 0.6 mm diameter probe, a 20 gram force was es ti m ated to m eas ur e s ul c us depth ( and l ong j unct i o n a l e p i t h e l i u m formation) and 60 gram force to measure most coronal connective tissue attachment.

fiigwrm .5. Schemotic drowingof concepts whtchwere presented thisreport.E tn p = enomel; = denttn; = cementum; = forceon the probe; = D C lCT.1 probe; areo of tnflommattan the bcseof the periodontol ot lCT, = loterolto the probe:p= pressure the probe oreo of tnflommotton of lnto the tissues; = reslstonce R ofthe trssue the probe; = dtometer to d
nf rha n,aho t tn P rc rlttorlh, ralnrad l^ tho fa,r o nn/1 tnd,t a.tl\ t

oreoot the end of the tip.Wttho roundprobe, = Flx(Dl2)'.Chonge P tn the probettp dtometer o greater hos effectthon chcnge E R is in
rlirertlt tplnle4 rn tissrtp mnrnhnlnat. i,c., 8 rnn(;(/dnl , [/55Ue

tha

tnflammotton, /oss connective cnd of tlssue cttcchment.The cltntcal pocketdepth (probtng depth) ls the mecsurement derivedfrom the
<irlenf rhe neriorlanrnlnrnhe tahen t he hre<qtre nf t he proDe cquot< ' the resistcnce ofthe glnglvc/ tlssues.

There is a great effort to standardize force2s but bec aus e of t h e g re a te r c l i n i c a l s i g n i fi cance, probe diameter should be standardized. There are numerous reports using various tip diameters (0.4 mm'33 :0 0. 5 m m ; 37- 4 20 .6 m m ' 4 3 ,4 40 .8 m m ;2 0 a n d 1.015,16). In a dog study, Keagle and Garnick43 defined the major function of the periodontal probe as an instrument to be used to discriminate changes in tissue inf lam m at ion . T h e p ro b e p e n e tra te d deeper i n

i nfl amed and l ess w i th heal thy ti s sue. Since t he probe di ameter i s a maj or factor i n pr obing, t hey compared force-displacement curves for probes with different diameters in healthy, inflamed and greatly i nfl amed ti ssues. P robe di ameters of 0. 6 m m discriminated best the different levels of gingival inflammati on and heal th; probi ng deeper wit h incr eased inflammation. The World Health Organization44proposed a probing tip with a hemispheric shape and a diameter of 0.50 mm. lt was felt that the rounded surface would produce less patient discomfort. However, the effect of this spherical configuration is not known,45 and it may be that this shape increases the area, thus reducing the pressure. The periodontal probe is the major instrument used in diagnosis and evaluation of treatment. Root planing or repositioned flap surgery achieve a long junctional epithelium with reduced sulcular/pocket depth and reduction of tissue inflammation. The periodontal probe shoul d be used to measur e t her apeut ic changes, but not the connective tissue attachment level since it is generally not modified by such treatment. lf the objective of probing is comparison of therapeuti c changes, then the pressur e should be cl ose to 50 N /cm2. If pressures of 200 N/ cm 2 or greater are used, the probe may p enet r at e t o t he base of the long junctional epithelium and not demonstrate the reduced sulcus/pocket depth (Fig. 5 and

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Table 1;.46tf the cliniciancan apply force of approximately 20 grams (0.20 N) on the periodontalprobe handle (in which the nail bed would not blanch), the probe tip diameter must be increased to 0.6 to 0.7 mm to reduce the pressure to the level of 40 to 50 N/cm2. At this pressure, the probe tip would be placed at the coronal end of the junctional epithelium, demonstrating the formation of long junctional epithelium.a6 CONCLUSION In summary, periodontal probing registersresistance of the tissues to the pressure applied by the probe. This pressureis directly proportionalto the application of force on the probe and indirectly to the area of the probe tip. The greaterthe pressure,the greater is the advancement of the probe into the tissues. However, the advancement depends on the resistance of the tissues at the site being measured. Variability in probing may result becausethe clinically observed inflammationmay not be the same as the inflammation in the tissues penetrated by the probe. However,with treatment,if the pressureis the same but the inflammation is reduced and/or tissue attachment is increased,the resistanceis increased and the displacementof the probe will be less. The difference in probing depth would measure reduction of inflammation and, therefore, effectiveness of treatment. The pressure used to measure the coronal level of the connectivetissue attachment is not the same as that used to place the probe at the base of the sulcus or the pocket, which should be much less. If the measurementof long junctional epithelium and reduced sulcular/pocket depth are the objectives of probing, then reduced pressures must be used. In this case, forces of 20 grams should be used with a probe tip diameter of 0.6 mm to obtain a pressure that would measure the new sulcus depth, but not penetratethe long junctional epithelium. The larger diameters that have been used for many years, as indicated in this report, would appear appropriate. RFFFRENCES 1. Greenstein Contemporary G. interpretation probing of depthassessments: Diagnostic and therapeutic implications. literature A review. Periodontol ;68:1194 J 7997 1205.
2. Armitage QC. Periodontal disease:Diagnosis.Ann Peiodontol 1996;7:37 -215.3. 3. Black GV. SpecialDentalPathologg.Chicago: MedicoDent alP ubli s h i n g o .; 1 9 1 5 :2 0 7 ,3 7 2 . C

4. Ramfjord SP. Indices for prevalence and incidence of periodontal disease.J Periodontol 1959;30:5 1-59. 5. Simonton FV. Examination of the mouth-with special reference to pyorrhea. J Am Dent Assoc 1925;72:287 295. 6. Box HK. Treatment of the PeriodontaLPocket. Toronto: The University of Toronto Press; 1928:83. 7. Miller SC. Oral Diagnosis and Treatment Planning. Philadelphia: Blakiston'sSon t' Co.; 1936:239. P. 8. HirschfefdI. Periodontiacase reporting. J Periodontol 7946;17:74-77. 9. Goldman HM, Schluger S, Fox L. PeriodontalTherapg. St. Louis: C.V. Mosby Co.; 1956:27. 10. Orban B, Wentz FM, Everett FG, Crant DA. Periodontics, A Concept-Theorg and Practice. St. Louis: C.V. Mosby C o.; 1958:103. 1 1. Glickman l. Clinical Periodontologg. Philadelphia: WB. SaundersCo.; 1958:548. 12. StillmanPR.The managementof pyorrhea.Dent Cosmos 1977:59:405-474. 13. Merritt AH. The pathology, etiology and treatment of pyorrhea. Dent Cosmos7978;60:574-581. 14. Merritt AH. Periodontal Diseases. New York: The Macmi l l anC o.; 1935:96-1 13. 15. Williams CHM. Some newer periodontal findings of practical importance to the general practitioner.J Can Dent Assoc 1935;2:333-340. 16. Williams CHM. Rationalization periodontalpocket of therapy. J Periodontol1943;14:67-7 1. 17. Sorrin S. The Practiceof Pertodontia.New York: Mccraw H i l l C o.; 1960:119. 18. Wade AB. Basic Periodontologg.Bristol: John Wright E S ons;1960:183. 19. Tibbetts LS. Use of diagnostic probes for detection of periodontal disease. J Am Dent Assoc 7967;78:549555. 20. Glavind L, Loe H. Errors in the clinical assessmentof periodontaldestruction.J PeriodontRes'1967 ;2:780784. 21. Kohler CA, Ramfjord SP. Healing of gingival mucoperiostealflaps. Oral Surg OraI Med Oral Pathol 1960;13: 89-103. 22. WaerhaugJ. The Gingiual Pocket.Oslo: Odontol Tidskr: 1952. 23. Zander HA. A method for studying "the epithelial attachment."J Dent Res 1956;35:308-312. 24. Orban BJ, Bhatia H, Kollar JA, Wentz FM. The epithelial attachment (the attached epithelial cuff). J Periodontol 1956;27: 167 - 180. 25. Schroeder HE, Listgarten MA. Fine Structure of the Deueloping Epithelial Attachment of Human Teeth. Basel,Switzerland: Karger; 1971. S. 26. Sivertson JF, Burgett FG. Probing of pockets related to the attachment level. J Periodontol 1976;47:281286. 27. RobinsonPJ, Vitek RM. The relationship between gingival inflammation and resistance to probe penetration. J Periodont Res 1979;14:239-243. 28. Hefti AF. Periodontal probing. Crit Reu Oral DioI NIed 1997:8:336-356. 29. Ustgarten MA. Periodontalprobing: What does it mean? J CIin PeriodontoL 798Ot7 65 - 176. :7

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30. van der Velden U, Jansen J. Microscopic evaluationof pocket depth measurements performed with six different probing forces in dogs. J Clin Periodontol 1981;8: 107 -116. 31. Qarnick JG, Keagle JG, SearleJR, King GE, Thompson WO. Gingival resistanceto probing forces. ll. The effect of inflammation and pressure on probe displacement in beagle dog gingivitis.J Periodontol1989; 60: 498- 505. 32. PolsonAM, Caton JG, YeapleRN, Zander HA. Histological determination of probe tip penetrationinto gingival sulcus of humans using an electronicpressure sensitive probe. J CIin Periodontol7980;7:479-488. 33. Kalkwarf KL, Krejci RF. Effect of inflammation on periodontal attachment levels in miniature swine with mucogingival defects.J Periodontol1983;54:361 -364. 34. Claffey N, Shanley D. Relationship gingivalthickness of and bleeding to loss of probing attachment in shallow sites following nonsurgical periodontal therapy. J C/in Periodo ntol 1986 ;13:654 -657 . 35. Claffey N, Loos ZB, GantesB, Martin M, EgelbergJ. Probing depth at re-evaluationfollowing initial periodontal theiapy to indicatethe initial ,"rptnre to treatment. J Clin Periodontol'1989;76:229-233. 36. MombelliA, Muhle T, Frigg R. Depth-force patternsof periodontal probing. Attachment gain in relation to probing force. J CIin Periodontol 1992;19:295-300. 37. BaderstenA, Nilveus R, Egelberg J. Effect of nonsurgical periodontaltherapy. Il. Severly advanced periodontitis. J CIin Periodontol 1984;71:63-76. 38. Mombelli A, Graf H. Depth-force patterns in periodontal probing. J Clin Periodontol 1986;13:126-130. 39. Watts TLP. Visual and tactile observationalerror: Comparativeprobing reliabilitywith recessionand cementoenamel junction measurements.Communtty Dent OraI Epidemiol 7989;77 :310-312. 40. Lang NP, Corbet EF. Periodontaldiagnosis in daily practice. Int Dent J 7995;45:3-15. 4 1 . Breen HJ, Rogers PA, Lawless HC, Austin JS, Johnson NW. Important differences in clinical data from third, second and first generation periodontal probes. J Periodontol1997 ;68:335-345. 42. Barendregt DS, van der Velden U, Reiker J, Loos BG. Clinical evaluationof tine shapeof 3 periodontalprobes using 2 probing forces. J Clin Periodontol 7996;23:397402.

43. KeagleJG, GarnickJJ, SearleJR, King CE, MorsePK. Cingival resistanceto probing forces I. Determination of optimal diameter.J Periodontol 1989;60:167-171. 44. Bulthus HM, Barendregt DS, Timmerman MF, Loos BG, van der Velden U. Probe penetration in relation to the connective tissue level: Influence of time, shape, and probing force. J Clin Periodontol 1998;25:417423. 45. Sanderink RBA, Mormann WH, Barbakow F. Periodontal pocket measurements with a modified plast0-probe and a metal probe. J Clin Periodonfol 1983;10: 11-21. 46. Keagle JC, Garnick JJ, Searle JR, Thompson WO. Effect of gingival wall on resistanceto probing forces. J Clin Periodontol 7995;22:953-957 . Send reprint requeststo: Dr. Jerry J. Garnick, Medical College of Georgia,School of Dentistry, Augusta,GA 309121220. Acceptedfor publicationDecember22, 1998.

2000 J Periodonml. January

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ChronicfilcerativeStomatitis:A CaseReport
Eduardo R. Lorenzana,*Terry D. Rees,f Marcia Glass,l and Jeffrey G. DetweilerS B ack g round: Certain mucocutaneous diseasespresent with painful, ulceratiue,or erosiueoral manifestations. Chronic ulceratiue stomatitis ts a newlg recognized disease of unknown ortgin which presents clinicallg with features of desquamatiue gingiuitis. This report marks onlg the thirteenth case reported i"n the world li"terature. reuiew of preuious reports and A studies is presented along with a reuiew of immunofluorescence techniques critical to proper diagnosis.Thesediseasesare difficult to diagnose without the use of immunofluorescence techniques.A 54-gearold Caucasian woman presented with a 2- to 3-gear historg of stomatitis and drg mouth. Methods: Direct immunofluorescence reuealed a speckled pattern of IgG deposits in the basal one-third of the epi.thelium,while indirect tmmunofluorescence confirmed the presenceof stratified epithelium-spectfic a ntin uc lear anti.g n (SES-A NA ), both p athog nomo nic e chronic ulceratiue stomatitis. for Results: The patient was successfullg treated using topical corticosteroid therapg. J Periodontol 20OO;77:104-111. KEY WORDS Gingivitis, necrotizing ulcerative/diagnosis; gingivitis, necrotizing ulcerative/drug therapy; gingivitis, desquamative/diagnosis; gingivitis, desquamative/drugtherapy; immunofluorescence techniques. Many skin diseases may presentwith painful, ulcerative, or erosive oral manifestations.These diseases often share similar oral featuresand definitivediagnosis is sometimes difficult. Diseasessuch as lichen planus, cicatricialpemphigoid, and pemphigus vulgaris are mucocutaneous disorders of unknown origin in which host antibodiesare directedtowardsthe epithelium andlor its junction with the underlying connective tissue. The presence of these antigenantibody complexesmay induce the epithelialdesquamation or erosion observed intraorally.Histopathological differentiation of these conditions is very important since clinical featuresmay be similar,but histologic findings are also often inconclusive.This may be especiallytrue in early lesions or in lesions in which the epitheliumhas desquamated. ln the last few years, immunohistochemistry techniques, especially direct and indirect immunofluorescence, have been used to clarify diagnosis.Direct (DIF) is performed by exposimmunofluorescence ing excised lesional tissue to antibodiesof various immunoglobulins, complement,and tissuebreakdown products.In indirect immunofluorescence (llF), normal stratifiedsquamous epithelium such as goat or monkey esophagustissue is exposedto labeled circulating serum antibodiesobtainedfrom the patient. A positive result is indicated if the labeled antibody binds with a tissueantigen.To date, distinct DIF features have been identified for lichen planus, pemphigoid, and the various forms of pemphigus.l-4 Although only pemphigusis associatedwith consistent positiveIIF findings,a limited number of reports have described a lichen planus specific antigen (LPSA) which, in one study, was found in B0% of patientswith lichen planus.5.6 Others have reported the "string of pearls" phenomenon using IIF which has been linked with lichenoid reactions to certain medications.T Recently, a distinct new disease entity, chronic ulcerativestomatitis(CUS), has been describedin a limited number of case reports.8-13 CUS resembles erosive lichen planus or oral discoid lupus erythematosus in its clinical and histologicmanifestations. Therefore,it is best diagnosed via immunofluorescence in conjunction with routine histopathology.DIF may reveal nuclear deposits of immunoglobulin G (lgG) in a speckledpattern mainly in the basal one-

* Currently,private practice,San Antonio, TX; previously, Baylor College of Dentistry,TexasA and M UniversitySystem, Dallas,TX. f Baylor Collegeof Dentistry. f Privatepractice,Dallas,TX; Baylor Collegeof Dentistry. $ HarrisMethodistSouthwestHospital,Fort Worth, TX.

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