PERIODONTAL PROBING

Arthur F. Hefti
Director, Periodontal Disease Research (enter, University of Florida College of Dentistry, JHMHC, P0 Box 100442, Gainesville, Florida 32610-0442
ABSTRACT: For decades, probing clinical pocket depth and attachment level have been recognized as the dentist's most
important tools in diagnosing periodontal health and disease. They are physical methods to measure the distance from the
bottom of a pocket to a reference line, usually the gingival margin or the cemento-enamel junction. Probing accuracy and pre-
cision are affected by factors like the design of the probe, probing force, probe position, pocket depth, or tissue inflammation.
Recently, several new electronic periodontal probes have been developed. They feature high instrument precision, allowing for
measurements to the nearest tenth of a millimeter. They control for probing force and permit data to be collected and stored
electronically. The purpose of this review paper is to summarize various aspects of periodontal probing. First, the history of
periodontal probes will be briefly recollected, and interesting and significant inventions of the past and the present empha-
sized. Then, the importance of the periodontal tissues relative to probe tip penetration will be reviewed, and the probing per-
formance will be discussed. The paper will conclude with notes on selected statistical issues.

Key words. Periodontal probes, probing, probing force, attachment level, measurement error.

(I) Introduction surement important for the clinical researcher, it is

Plaque-induced periodontal diseases can be grouped
as afflictions of the gingiva, i.e., gingivitis, and the
periodontium, i.e., periodontitis. Gingivitis is defined by
the reversible presence of gingival inflammation without
loss of connective tissue attachment. In contrast, perio-
dontitis is defined by the presence of inflammation of
the gingiva and the adjacent attachment apparatus.
Clinically, the disease can be identified by irrevocable
loss of connective tissue attachment due to destruction
of the periodontal ligament, and loss of supporting alve-
olar bone. The periodontal pocket is the cardinal symp-
tom of periodontitis. It is a pathologic fissure between
tooth and sulcular or pocket epithelium, limited at its
base by the junctional epithelium. It is an abnormal api-
cal extension of the gingival sulcus caused by an exten-
sion of the junctional epithelium along the root surface
and formation of a pocket epithelium as the periodontal
ligament is detached and destroyed by the disease
process (AAP, 1992).
The number, type, depth, and extension of periodon-
tal pockets constitute a record of disease history. The
correct identification and accurate assessment of perio-
dontal pockets is therefore of fundamental importance
for the diagnosis of periodontitis. In addition, the identi-
fication of changes in periodontal pockets is important
for the evaluation of disease severity, disease progres-
sion, and therapeutic efforts. Not only is pocket mea-
equally important for the clinician in daily practice.
However, in a survey conducted in general practices in
North Carolina, McFall et al. (1988) found that only 14.5%
of the audited records included probing information.
Another study reported that in only 62% of the surveyed
practices were complete periodontal recordings per-
formed routinely on new patients (Heins et al., 1989).
Such data hint that assessment of periodontal pockets
may be a troublesome task.
Periodontal pocket examination should be accurate,
technically simple, and quick. To date, the periodontal
probe is the only instrument that has been found to be
reliable and convenient in pocket examination.
Periodontal probes are designed to facilitate pocket or
attachment level measurements at any tooth site. A
probe consists of three parts, including handle, shank,
and tip. The tip is the working end and is usually cali-
brated with millimeter markings. Probe tip and shank are
positioned relative to each other in a defined angle of
usually greater than 90°. Most periodontal probes are
made of stainless steel, but more recently titanium and
plastic have been used as well. Brief descriptions of a
selected number of probes are presented in (II) below.
The periodontal probe is introduced into the pocket
parallel to the root surface, with slight force used until
further penetration is limited by increased resistance as
the probe tip approaches the bottom of the pocket. It will
be shown in (III) below that the final position of the

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probe tip is determined by several factors, including
examiner skills, probe design, and tissue condition.
Conceptually, pocket examination is intended to reflect
the distance from the bottom of the pocket to the gingi-
val margin. In clinical reality, a surrogate is used. It is
called probing depth and assesses the distance from the
probe tip to the gingival margin. In addition, in order to
distinguish clearly between true anatomical defect and
clinical measurement, Listgarten (1972) proposed the
use of the more accurate terminology "histologic pocket
depth" and "clinical pocket depth", respectively.
Periodontal probing is of relevance because it per-
mits the dentist to identify sites with a history of perio-
dontal disease or at risk for periodontal breakdown. But
probing depth measurements do not always reflect the
extent of periodontal destruction. Frequently, the gingi-
val tissue is inflamed or it is overgrown in response to
drug therapy (Hassell and Hefti, 1991). In such cases,
probing depth is a measure of pseudopocketing, and the
extent of periodontal destruction is (grossly) overesti-
mated. In contrast, in situations of gingival recession or
after periodontal surgery, probing depth can substantial-
ly underestimate the true extent of periodontal destruc-
tion. A better reflection of periodontal destruction can be
obtained by the measurement of the clinical attachment
level, i.e., the distance from the probe tip to the level of
the cemento-enamel junction (CEl). Sometimes,
because it is difficult to identify the CEJ, the measure-
ment of a relative attachment level is preferred. In such
situations, a restorative margin, stent, incisal edge, or
occlusal surface is used as a clinical reference line, and
the relative attachment level is measured from the probe
tip to the reference line.
This review will summarize various aspects of perio-
dontal probing. First, the history of periodontal probes
will be briefly recollected, and significant inventions of
the past and the present emphasized. Then, the tissue
under investigation will be presented. The probe tip pen-
etration as compared with the apical termination of the
junctional epithelium and the probing performance will
be discussed. The paper will conclude with notes on
selected statistical issues in periodontal probing.
(11) A Short History of Periodontal Probes
For consistency, in the following discussion, the probe
classification proposed by Pihlstrom (1992) will be
applied. Conventional, manual probes that do not con-
trol for probing force or pressure and that are not suited
for automatic data collection will be called first-genera-
tion probes. The introduction of constant-force or pres-
sure-sensitive probes allowed for improved standardiza-
tion of probing. These probes will be called second-gen-
eration probes. Computer-assisted direct data capture
was an important step in reducing examiner bias and
also allowed for greater probe precision. Probes exhibit-
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ing such features, in addition to controlling for probing
force, will be classified as third-generation probes.
(1) FIRST-GENERATION PROBES
The American dentist John M. Riggs (1811-1885) investi-
gated diseases of the gingiva extensively and in 1867
postulated that they could be treated effectively. Riggs
offered his patients a form of non-surgical therapy which
consisted of a very thorough subgingival curettage to
eliminate diseased tissue and calculus that had accumu-
lated on the root surfaces. To remove calculus, he used a
set of six scaler-like instruments. Riggs obtained excel-
lent results, and in recognition of his outstanding
accomplishments, alveolar pyorrhea was renamed "Riggs
disease". Riggs' therapy was applied by other dentists,
especially D.D. Smith and W.Y. Younger in Europe. Today,
Riggs, Smith, and Younger are considered the pioneers
of conservative periodontal therapy. They faced opposi-
tion from a small group of specialists who clearly favored
the surgical approach. However, Riggs vehemently disap-
proved of periodontal surgery and described it as being
of barbaric origin (Riggs, 1882). Until Riggs, there was no
description of a periodontal probe in the literature. By
and large, alveolar pyorrhea was diagnosed based on
suppuration and increased tooth mobility.
In his text Treatment of the periodontal pocket, H.K. Box
(1928) depicted a set of six periodontal probes.
Unfortunately, Box neglected a description of the instru-
ments, but W.G. Cross (1966), who used and improved
them, provided some details. Three probe types were
manufactured, exhibiting differences from each other in
size and form of the blades. Probes were made of soft
Sterling silver and were suitable for pocket measure-
ments in all areas of the dentition. Markings from 1 to 16
mm were engraved on one side of the blade, and sepa-
rate instruments for the left and right sides were avail-
able. The 2-, 4-, and 6-mm markings were emphasized to
make pocket depth reading easier.
G.V. Black (1887) differentiated between two forms of
periodontal disease: "calcic pericementitis" and "phage-
denic pericementitis". He postulated that both forms of
disease would result in pockets which he examined using
a pair of specially constructed probes. The probe tips
were flat blades 1.5 mm wide and 8 mm long and slight-
ly bent to the left or the right side, making them perfect-
ly suitable for easy insertion. Millimeter markings were
available, but, according to Black, in practice it was
absolutely sufficient to estimate pocket depth based on
the length of the tip not inserted into the pocket. It
seems that Black also used endodontic files, especially
in situations of difficult access.
To date, the periodontal probe developed by C.H.M.
Williams (1936, 1943) has been one of the most popular
instruments for the examination of pockets. Williams
was a periodontist who specialized in the study of the
33
337

- probing with this instrument was quite
Figure 1. Periodontal probes for the meosurement of pocket depth and attachment level
Several examples are shown (1-r): PCP 8, PCP 10, PCP 11, PCP 12, PCP-UNC 15 mann, at the Zahnarztliches Institut
(University of North Carolina), Michigan 'O', Goldman-Fox, Glickman, Williams, Zorich in Switzerland, presented a modi-
CPITN (WHO).
relationship between pocket formation and focal infec-
tion. He requested that dentists assess the number, size,
type, and localization of pockets and use the information
for the early recognition of periodontal disease. Williams
used a probe with a thin stainless steel tip of 13 mm
length and a rounded tip end The tip diameter was 1.0
mm. Pocket depth was estimated from millimeter mark-
ings at 1, 2, 3, 5, 7, 8, 9, and 10 mm. Probe tip and han-
die enclosed a 130° angle. This instrument can be regard-
ed as being the prototype probe for most subsequent
developments, like the Merritt probes and the University
of Michigan probe
In Europe, periodontal probes appeared for the first
time in the late 1920s. Sachs (1929), a German periodon-
tist who received his specialty training from 1908 to 1909
in R. Good's practice in Chicago, constructed the
"Paradentometer", using a thin, 1.3-mm-wide V2A steel
blade. Six grooves at 2 mm distance from each other
allowed pocket depth to be assessed The blade was
bendable and enabled the dentist to probe pockets that
were very difficult to access. In 1934, Struckmann in
Germany described the Duka Taschenmass, a set of 6
probes made of stainless steel. Probe tips were from 3 to
8 mm long and could be adapted by finger pressure to fit
pocket morphology. The first measurement was usually
made with the size 6 probe, and subsequent measures
used the most appropriate size as estimated based on
the first measurement. E.W. Fish presented his probe in
1946. In contrast to the current opinion, Fish thought
that it would not be necessary to calibrate the tip length,
but he emphasized that the tip end should be round to
minimize patient discomfort due to probing. The tip of
Fish's probe was round, tapered, and 10 mm long. It was
connected perpendicular to the probe handle.
Modifications of Williams' probe were described by
many authors. The best-known examples are probably
the probes of Goldman and Fox, Nabers, Drellich, Cross,
and Gilmore Besides the pioneering work in the USA
338 Crii Rev
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and Europe, a series of interesting de-
velopments was made in Japan by
Kimura at the Tokyo Medical and Dental
University. He described a double-ended
instrument that exhibited tips with semi-
oval cross-section, The tapered, 15-mm-
long tip was marked with 9 color-coded
bands of 0.7-mm width. The bands were
separated by 0.3-mm-wide rings, which
were easy to read and could also be iden-
tified on x rays According to Kimura,
reproducible and fast In 1960, Mi1hle-
fication of Williams' probe, The ZIS probe
exhibited a 1 150 angle between shank
and tip, and the tip end exceeded the long axis by 13
mm. The probe was calibrated at 3, 6, and 9 mm. Today,
the University of North Carolina probe (PCP-UNC 15, Hu-
Friedy Manufacturing Co., Chicago, IL), with color coding
of every millimeter demarcation, is probably the pre-
ferred instrument in clinical research if conventional
probes are required, A selection of probes is presented in
Fig. 1.
The World Health Organization (WHO) recommend-
ed a special periodontal probe for use with the commu-
nity periodontal index of treatment needs (CPITN; WHO,
1978). It is different from other probes because of its
ball-end of 0.5 mm in diameter, which is attached to a 16-
mm-long tapered tip. Tip and shank, and shank and han-
dle include angles of 90° and 30°, respectively. The tip of
the clinical probe has markings at 3 5, 5.5, 8.5, and 11.5
mm. The ball-end permits the clinician to detect root
surface roughness like calculus deposits The probe has
been advocated for use in epidemiology and the routine
periodontal screening of patients in general practice.
By and large, the abovementioned probes were con-
structed according to the same principles They consist-
ed of one piece including handle, shank, and tip They
differed from each other in such factors as angulation,
size, cross-sectional shape, and calibration. However,
some of the first-generation probes were quite different
in design and are worth a closer look The Kryptometer
was described by the periodontist Christian Hulin (1888-
1977). The Frenchman was best-known for his pioneering
animal studies on periodontal disease and theories on
the physiology of alveolar bone atrophy. According to
Hulin, in addition to simple gingivitis, which he thought
of as a specific inflammatory disease of anaphylactic
nature, alveolar bone atrophy would ultimately be
responsible for the inevitable tooth loss. Hulin's probe
had the design of a syringe equipped with a curved can-
ule and a calibrated piston. The four markings on the pis-
ton were thought to correspond to four degrees of dis-
336 356 119971
8630036-356 (97
ease severity. Also, he proposed a pocket recording chart
based on four levels of disease severity. The pocket chart
allowed the periodontist to read, at a glance, both sever-
ity and extent of periodontal involvement. The
Kryptometer was the starting point for many interesting
developments, including probes by Starke (1937),
Krihning (1939), Ward (1963), and Breese (1966).
In 1967, Schmid presented the Plast-O-Probe pro-
bing instrument. He had noticed that regular probes
were too thick and rigid to allow for accurate inspection
of pockets and developed a probe consisting of a metal
handle and a disposable plastic tip. The flexible blade-
shaped tip granted better access to pockets and adapta-
tion of the probe to the root surface. It was fabricated of
low-pressure polyethylene and consisted of three parts.
The head, connecting the tip to the handle, was cup-
shaped. It was attached to a 6-mm-long neck that blend-
ed into the 9-mm-long calibrated working end. At the
inserting end, the tip was only 0.2 mm thick and 1.5 mm
wide. Probing depth was marked at 3, 6, and 9 mm. The
joint between handle and tip allowed the examiner to fit
the probe to almost any tooth type and probing site.
Schmid investigated the performance of the Plast-O-
Probe in a series of experiments that included assess-
ment of probing depth in vivo and on the extracted tooth,
comparison of probing depths as measured by means of
the Plast-O-Probe and by a standard probe, determina-
tion of probing forces during the insertion of the Plast-O-
Probe as compared with a standard probe, and evalua-
tion of patient pain during probing. Some of Schmid's
findings will be discussed in the next section.
(2) SECOND-GENERATION PROBES
Probing of periodontal pockets has long been accepted
as the gold standard for the determination of periodon-
tal conditions. However, it was not until Muhlemann and
Mazor (1958) and, later, Muhlemann and Son (1971)
described bleeding on gentle probing as the leading
symptom of gingivitis that controversy initiated around
what "gentle probing" really means. Earlier, Waerhaug
(1952) had suggested that pockets should be assessed
using "light hand pressure". He had estimated that pro-
bing pressure, as measured at the probe tip, should not
exceed 0. 2 N/mm2. Schmid (1967) investigated 48 pock-
ets exhibiting an average depth of 4.6 ± 1.9 mm in three
subjects with adult periodontitis and found that a pro-
bing force of, on average, 0.226 N was sufficient to guide
the flat plastic tip of the Plast-O-Probe into the cleft of a
periodontal pocket. In comparison, an average force of
0.363 N was applied by the examiner using the ZIS perio-
dontal probe to inspect the same pockets. In these
experiments, the instrument used to measure force con-
sisted of a dynamometer with the probe tip attached to
the end of the lever arm. This probe was not suitable for
full-mouth examination. The first true pressure-sensitive
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periodontal probe was developed by Gabathuler and
Hassell (1971) with the objective of quantitating "gentle
probing". It consisted of a standard ZIS periodontal
probe and a small piezoelectric pressure sensor, which
was attached to the non-probing end of the probe tip.
Probing forces were transferred from the tip to the sen-
sor via a piston arrangement, and the electric potential
generated in the piezo element was amplified, stored on
tape, or converted into a printer signal. Eight experi-
enced clinicians independently examined ten young
adults with healthy gingivae. Probing force, probing
depths, and bleeding upon probing were recorded.
Average force per examiner ranged from 0.198 ± 0.074 N
to 0.320 ± 0.121 N. The overall mean probing force was
0.246 ± 0.089 N. The data did not suggest a cause-and-
effect relationship between force applied and occurrence
of bleeding in healthy subjects. In a subsequent experi-
ment that included six clinicians, Hassell et al. (1973)
examined five subjects exhibiting different degrees of
severity of adult periodontitis. Using the same pressure-
sensitive periodontal probe as in the previous study, they
found a wide range of probing forces, varying, on aver-
age, from 0.235 N to 1.127 N.
These findings and a series of investigations that
identified a positive correlation between probing force
and depth of probe penetration led to the construction
of probes with constant probing force. Armitage et al.
(1977) investigated the accuracy of clinical attachment
levels using a pressure-sensitive probe holder. It was
made from a 16-gauge transparent catheter around a
needle, a needle shaft, and a spring that was placed
around the needle shaft. The needle shaft could be
moved into the catheter. The extent of insertion was
determined by the force of the spring. The instrument
was calibrated for forces from 0.15 N to 0.35 N in 0.05-N
increments. Any kind of probe tip could be attached to
the needle shaft. In their study, Armitage et al. used a
probing force of 0.25 N and a Michigan '1' probe tip with
a terminal diameter of 0.38 mm which resulted in a pro-
bing pressure of 2.20 N/mm2.
In 1978, van der Velden and de Vries presented the
"Pressure Probe", which allowed probing force to be
adjusted. Basically, the working end of their probe con-
sisted of a 1-mm-diameter metal cyclinder that was bent
at an angle of 130°. Movable inside the cyclinder with
minimal friction was a 0.63-mm-diameter piston. The
probe was calibrated from 0 to 9 mm in 1-mm incre-
ments. The 5-mm marking was clearly delineated. Air
pressure acted on the piston at defined force levels from
0.1 to 1.5 N, resulting in probing pressures from 0.32
N/mm2 to 4.81 N/mm2. An electronic pressure-sensitive
probe was presented by Polson et al. (1980). Their instru-
ment consisted of a pen-like handpiece with probe tip
and an electronic control unit that allowed the probing
force to be set at any level from 0.05 N to 1 N. The allow-
339
able probing force was determined by an electromagnet-
ic force that held an air gap shut until the pre-set pro-
bing force was reached, at which point the gap opened
and a sound was produced. A variety of probing tips
could be attached to the handpiece. Polson and his
group used a 0.35-mm-diameter Hu-Friedy #26GL probe
tip and set the probing force at 0.25 N (2.60 N/mm2).
Today, the probe is better known as the "Yeaple probe"
and is frequently used in studies of dentinal hypersensi-
tivity (Kleinberg et al., 1994). A simple, constant-force,
periodontal probe was presented by Borsboom and co-
workers (1981). Their instrument used a stainless steel
spring to generate constant force. The spring was applied
in a rotating system, wound on two cylinders in a
reverse-winding mode to exert constant torque. One
cylinder was mounted concentrically with the hinge and
attached to the probe tip. The other cylinder was
attached to the handle. The special arrangement of the
springs resulted in an angle-independent torque and
reduced static system friction. Probing force was 0.13 N
for standard measurements, but forces of 0.26 N and 0.57
N were also possible.
(3) THIRD-GENERATION PROBES
The objective of the design of the probes described in
Section 11/2 was to reduce measurement variation by
standardizing probing force. Other important sources of
probing error include reading the probe, data recording,
and calculation of attachment level. These errors origi-
nate from human negligence and can be avoided by the
use of computers. The first controlled probing force
probe that was capable of automated detection of the
CEJ for determination of attachment levels and allowed
for computerized data recording was presented by
Jeffcoat et al. (1986). The components of their probe
include a pneumatic cylinder that pushes the core of a
linear variable differential transducer, the force transdu-
cer, the accelerometer, and the probe tip forward until
they attain the final position at the bottom of the pock-
et. Tip movement is at controlled speed and pre-set
force. As the probe glides along the root surface, the tip
is subject to abrupt changes in acceleration when it
meets the CEJ and when it is stopped at the pocket base.
The tip then retracts automatically. Attachment level is
computed based on the time the probe tip used to move
between the two acceleration bursts and the speed of the
tip movement. The probe tip consists of a Teflon-coated
thin steel wire with a ball-shaped end 0.5 mm in diame-
ter. Probing force is adjustable between 0 N and 0.49 N,
corresponding to probing pressures between 0 N/mm2
and 2.50 N/mm2, respectively.
Following a workshop on the Quantitative Evaluation
of Periodontal Diseases by Physical Measurement
Techniques, the National Institute of Dental Research
(NIDR) issued a Request For Proposals (RFP) to develop
340 Grit Rev
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and clinically evaluate an improved periodontal pocket
depth and attachment level measurement system. In
response to the RFP, Gibbs et al. (1988) developed the
Florida Probe® system, which features constant probing
force, precise electronic measurement, computerized
data capturing, and sterilization of all system parts enter-
ing or close to the mouth. The system consists of a probe
handpiece, a digital read-out, foot switch, computer
interface, and computer. The probe tip reciprocates
through a sleeve and is connected to a movable arm,
which transfers the movement to a transducer with digi-
tal read-out. Initially, the probe tip resembled the
Michigan 'O' probe tip. It was tapered and had a spheri-
cal end measuring 0.4 mm in diameter. The adjustable
probing force is usually set at 0.25 N (1.99 N/mm2).
Recently, a new titanium flat-end probe tip with a uniform
diameter of 0.45 mm was presented (Ramirez et al., 1996).
The tip is flexible, a feature which improves its ability to
fit the tooth contour. The slightly enlarged diameter
reduces the probing pressure to 1.57 N/mm2. Besides the
pocket depth probe, two versions of the Florida Probe®
handpiece are available for the determination of relative
attachment levels: the stent probe and the disk probe.
The former uses an acrylic stent as a reference and for the
reproducible placement of the probe tip. The latter has a
small metal disk attached to the sleeve and uses the
occlusal surface or incisal edge of a tooth as a reference
for relative attachment level measurement.
Goodson and Kondon (1988) used fiber optic tech-
nology in their controlled-force Accutek probe. The probe
tip is attached to an optical encoder transducer element.
A fiber bundle transmits light to the transducer and
reflected light to a signal processor. Probing depth is
computed by comparison of the reflected light signal
with the reference obtained from the zero position.
Controlled probing force at 0.4 N (4.16 N/mm2) is provid-
ed by a friction clutch mechanism. The disposable flexi-
ble plastic probe tip has a diameter of 0.35 mm. The sig-
nal can be processed for direct output on a liquid crystal
display or stored in computer memory for subsequent
listing or transfer to a host computer. The InterprobeTM
electronic probe system is similar to the Accutek system.
It is calibrated for a constant 0.3-N (1.26 N/mm2) probing
force and uses a 0.55-mm-diameter plastic filament.
Birek et al. (1987) and McCulloch et al. (1987) devel-
oped the Toronto automated periodontal probe, which
incorporates controlled probing force, electronic data
collection and storage, and reproducible probing angula-
tion. The probe consists of a digital length gauge con-
nected to a co-axial wire 0.5 mm in diameter. The wire is
enclosed in a plastic sheath and is the probe tip. Probing
forces from 0.1 N to 0.9 N, corresponding to probing
pressures from 0.51 N/mm2 to 4.58 N/mm2, can be gene-
rated by an electric torque motor contained in the length
gauge. Digitized data can be recorded from the length
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gauge. The Toronto probe uses the incisal or occlusal
surface of the tooth as the reference landmark for relative
attachment level measurements. A mercury switch
ensures reproducible probe angulation (Karim et al.,
1990), because it forces the examiner to hold the probe
within ± 100 of a vertical position. Recently, the Toronto
probe was modified for the measurement of probe pene-
tration velocity (Tessier et al., 1994).
The Peri-Probe system includes a constant-force
probe and a data processer/printer unit. The probing force
is generated by a coil spring and ranges from 0.21 N (1.07
N/mm2) for deep pockets to 0.46 N (2.34 N/mm2) for the
measurement of shallow pockets (Bose and Ott, 1992). A
flexible wire with a diameter of 0.3 mm and a ball-shaped
end 0.5 mm in diameter are used for pro-bing. The probe
tip is contained in a disposable sleeve, the end of which
serves as a reference for probing depth measurements.
(111) The Periodontal Tissues
Comprehensive, scholarly reviews of the composition
and functions of tissues and cells of the periodontium
have been recently published by Schroeder (1991) and
Hassell (1993). In addition, Schroeder (1991) has sum-
marized the probing process from the structural biology
point of view. These documents have formed the basis of
the following discussion.
The structures collectively called the periodontium
include the gingiva, the periodontal ligament, the root
cementum, and the alveolar bone. An understanding of
the basic histology and function of the periodontal tis-
sues and their alterations due to disease is essential for
the comprehension of the probing process and the inter-
pretation of its results, because it is the tissue that ulti-
mately determines the path of the probe tip. In the fol-
lowing, these relationships are surveyed briefly.
The gingiva covers the alveolar bone and forms a
dynamic seal surrounding the teeth. Clinically, the facial
(buccal) and lingual marginal gingivae can be distin-
guished from the interdental gingivae, i.e., the facial
(buccal) and lingual papillae, which connect at the inter-
dental col. The gingiva is comprised of epithelium and
connective tissue, blood vessels, and nerves. The epithe-
lium exhibits two structurally and functionally different
phenotypes, the keratinized stratified epithelium of the
oral gingiva and sulcus, and the non-keratinized junc-
tional epithelium. The connective tissue component is
mostly composed of collagen, with the individual fibrils
arranged into the independent fiber groups. It also con-
tains the blood vessels and nerves. The interface
between gingiva and tooth surface, the dentogingival
junction, exhibits two different attachment mechanisms
(Schroeder and Listgarten, 1977). The free marginal gin-
giva adheres to the tooth surface through the epithelial
attachment, which is comprised of the internal basal lami-
na and hemidesmosomes. The connective tissue attachment is
8(3)336-356~~~~~~
(19)Ci e rlBo e
8(3):336-356 (1997) Crit Rev Oral Biol Med
formed by collagen fiber bundles, which insert into the
supra-alveolar cementum between the alveolar crest and
the CEJ. In the ideal situation of a completely healthy
periodontium, the two attachment structures meet at the
level of the CEJ, although some apical or coronal dis-
placement is frequently seen (Schroeder, 1986). The
junctional epithelium is clinically not visible and extends
from the CEJ to the bottom of the gingival sulcus, much
like a cuff. At the bottom of the sulcus, it is continuous
with the oral sulcular epithelium, or, in rare cases, it con-
tinues directly into the gingival epithelium. In the inter-
proximal space, the junctional epithelia of adjacent teeth
merge and form the interdental col.
(I) PROBING THE HEALTHY,
NON-INFLAMED PERIODONTIUM
Assessment of the approximately 0.5-mm-deep healthy
gingival sulcus by means of a periodontal probe general-
ly results in an overestimation of true sulcus depth.
When the probe is inserted into the sulcus, it easily pen-
etrates the junctional epithelium at the bottom of the
sulcus, which does not offer any significant resistance to
probing. The probe tip then penetrates the junctional
epithelium, leaving the basal lamina and some cell lay-
ers attached to the tooth surface. The resistance of the
adjacent connective tissue increases toward the den-
togingival junction, where further penetration of the
probe is halted by the pressure of the dense network of
collagen fibers, especially the dentogingival fiber bun-
dles (Armitage et al., 1977). Polson et al. (1980) were able
to demonstrate experimentally the relationship of the
probe tip to the dentogingival junction by determining
the depth of probe tip penetration into clinically healthy
gingival sulci. For their study, they used a pressure-sen-
sitive probe pre-set at a probing force of 0.25 N. The
probe tip exhibited a terminal diameter of 0.35 mm. A
histologic landmark of probe tip location was made with
a scalpel, and gingival biopsies were taken during perio-
dontal surgery for the elimination of adjacent pockets. A
histometric analysis showed that probe tip penetration
was 0.25 ± 0.19 mm coronal to the apical end of the junc-
tional epithelium and 0.70 ± 0.56 mm apical to the coro-
nal end of the junctional epithelium.
A clinically determined probing depth of 1 to 3 mm is
usually observed when the sulcus of healthy gingiva is
probed. With respect to their topographic location,
approximal sulci are slightly deeper than lingual sulci.
Buccal sulci exhibit the least depth. There is no bleeding
upon probing in the healthy sulcus because blood vessels
in the connective tissue are not injured by the probe. As
a rule, healing of the epithelial cleft following probing is
achieved within 5 to 7 days (Taylor and Campbell, 1972).
(2) PROBING THE INFLAMED PERIODONTIUM
Micro-organisms of dental plaque are the single most
341
important etiologic factor influencing gingivitis and perio-
dontitis. Plaque bacteria preferably colonize the tooth
surface along the well-protected space formed by the
gingival sulcus, triggering an initially mild inflammatory
reaction in the adjacent gingival tissue. If the pocket
depth is assessed under such conditions, the probe will
likely penetrate through the junctional epithelium, but it
will be stopped quickly by the resistance of the impene-
trable arrangement of intact connective tissue fiber bun-
dles in the gingival connective tissue. The clinical pro-
bing depth will be similar to that measured in the com-
pletely healthy tissue. Because the probe advances into
slightly inflamed connective tissue, some minor bleeding
on probing may be observed as the result of injury to
blood vessels.
If the inflammation persists, exudate containing pro-
teolytic enzymes and transmigrating neutrophils moving
into the gingival sulcus may loosen the epithelial attach-
ment and allow for the apical expansion of plaque. Once
plaque is established subgingivally, the junctional
epithelium remains separated from the tooth surface,
and spontaneous re-attachment will not occur. The junc-
tional epithelium will then transform into a pocket
epithelium, which typically features irregular epithelial
ridges, thin inter-ridge coverings, micro-ulceration, and
strong infiltration of the epithelial ridges by lympho-
cytes, blast cells, and plasma cells. The epithelium is
highly permeable for a great variety of compounds, and
there is increased migration of PMNs in the direction of
the bacterial challenge (Muiller-Glauser and Schroeder,
1982; Page, 1986). The resulting fissure between tooth
and epithelium is now called a gingival pocket. At the
most apical end of the pocket, the pocket epithelium
proceeds seamlessly into the junctional epithelium,
which continues to maintain an epithelial attachment of
greatly reduced height. The periodontal probe will easily
traverse the pocket epithelium and penetrate more or
less deeply into the connective tissue, as shown by
Magnusson and Listgarten (1980) and Fowler et al. (1982).
The magnitude of tissue penetration will depend on the
presence, severity, and extent of inflammation, but usu-
ally the probe will be stopped at approximately the level
of the dentogingival junction (Listgarten, 1980). Some
overestimation of the gingival pocket depth is very likely.
Concomitant with the establishment of the inflam-
matory lesion, increased vasculitis and vascular prolifera-
tion will be noted. The periodontal probe will injure many
of the delicate blood vessels as it passes across the
inflamed connective tissue, which will lead to bleeding
on probing. The clinical sign of bleeding on probing has
been explored and described in great detail (Greenstein et
al., 1981; Lang et al., 1990, 1991). It is now a standard param-
eter of every comprehensive periodontal examination.
Occasionally, the destructive process will not cease
at the CEJ, and the area of collagen breakdown will
342 Crit Rev Oral
Crit Rev Oral Biol
Biol Med
increase in the presence of plaque-induced inflamma-
tion. The principal fiber bundles inserting into root
cementum become included in the infiltrate and will be
destroyed, leading to an apical shift of the residual junc-
tional epithelium, i.e., attachment loss. A periodontal pock-
et develops. The probing of periodontal pockets has
been extensively investigated. Listgarten and co-workers
(1976), using periodontally damaged teeth that were
marked prior to extraction, noted that in the presence of
inflammation the probe penetrated approximately 0.3
mm into the infiltrated connective tissue until it was
stopped by collagen fibers or the crest of the alveolar
bone. A number of studies have investigated probing
depth in relation to the location of the probe tip in treat-
ed and untreated periodontal pockets. Armitage et al.
(1977) used beagle dogs to examine connective tissue
attachment levels in clinically healthy gingiva, experi-
mental gingivitis, and periodontitis. For the measure-
ments in healthy animals and animals with gingivitis,
they used a constant-force probe with a terminal diame-
ter of 0.38 mm and 0.25 N probing force. In dogs with
periodontitis, a Michigan 1 probe of 0.35 mm in diame-
ter was inserted by means of "gentle" force. Histometric
evaluation showed that in healthy gingiva and in experi-
mental gingivitis, the probe penetrated the junctional
epithelium but failed to reach its apical end by 0.39 ±
0.51 mm and 0.10 ± 0.19 mm, respectively. Periodontitis
affected the probe position to a significant extent. In
some samples, the probe penetrated through the epithe-
lium into the connective tissue. In other samples, a con-
nective tissue fiber layer stopped the probe at a short
distance from the alveolar bone crest. On average, the
probe tip progressed 0.24 ± 0.38 mm into the connective
tissue. Magnusson and Listgarten (1980) inserted metal
strips of 30 mm in length, 1.5 mm in width, and 0.075 mm
in thickness into periodontal pockets using light pres-
sure. By preparing reference notches, they marked the
level of the gingival margin in the teeth, which were
treatment-planned for extraction. The level of the apical
delineation of the notch was indicated on the strip with
a sharp instrument. After tooth extraction, the apical end
of the strip was marked in the root surface. Sections were
then prepared for histometric analysis. It was found that,
in non-treated pockets . 4 mm, the strip penetrated, on
average, 0.29 ± 0.50 mm into the connective tissue apical
to the junctional epithelium. In contrast, in pockets of >
4 mm receiving scaling and root planing, the probe tip
stopped within the junctional epithelium, on average,
0.31 ± 0.49 mm short of the coronal level of the connec-
tive tissue attachment. In pockets of less than 4-mm
probing depth, the strip usually stopped at the coronal
level of connective tissue attachment. Garnick et al.
(1980) compared probings of untreated and scaled perio-
dontal pockets in patients with periodontitis. They con-
trolled the probing force using a hand-held leaf gauge,
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making sure not to exceed 0.20 N. Histometric analysis
demonstrated that probe penetration, expressed as the
distance from the probe tip to the base of the junctional
epithelium, was not dependent on pocket depth or the
degree of inflammation. However, in their study, the
probe tip penetrated beyond the base of the junctional
epithelium and was stopped by condensation of connec-
tive tissue fibers. Fowler and co-workers (1982) applied a
similar study design to examine the histologic probe
position in pockets exhibiting probing depth of . 6 mm.
Untreated teeth were compared with teeth that were
treated until measurements indicated stabilization and
no further improvement of periodontal conditions. To
apply the standardized probing force of 0.50 N, they used
an electronic pressure-sensitive device (Polson et al.,
1980) with a probing tip of 0.4 mm in diameter.
Histologic examination determined that, in untreated
sites, the probe tip progressed 0.45 ± 0.34 mm beyond
the apical termination of the junctional epithelium and
into the subjacent connective tissue. In treated sites, the
probe stopped 0.73 + 0.80 mm shy of this landmark.
More recently, Hull et al. (1995) investigated the validity
of probing depth measurements by comparing the
results obtained with the constant-force Florida Probe®
with those obtained from use of a manual PCP 10 probe.
Thirty-three teeth from 15 subjects were included in the
protocol that resulted in a statistically significant sys-
tematic underestimation of pocket depth by an average
distance of 0.48 mm (95% Cl: 0.25 mm to 0.70 mm) when
pockets were probed with the constant-force probe. In
contrast, the manual probe penetrated the pocket
epithelium, which led to a statistically insignificant over-
estimation of pocket depth by 0.08 mm (95% CI: -0.3 mm
to 0. 15 mm). The authors concluded that the validity of
the constant-force probe was sufficient but less than that
of the conventional probe.
The consequences of anatomical differences for
probing molar furcation sites have not been investigated
in great detail. Moriarty et al. (1989) histologically exam-
ined probe position relative to classes II and III furcation
sites. Pockets located at buccal furcation sites were
assessed by means of an electronic pressure-sensitive
probe with a pre-set force of 0.50 N and supplied with a
Michigan 'O' probe tip 0.40 mm in diameter. Following
careful probe placement, probe tips were affixed to the
teeth, and block biopsies were surgically removed. The
results demonstrated that probe tips penetrated the con-
nective tissue, on average, by 2.1 ± 0.6 mm, and in most
specimens the probe tip was located below (0.4 ± 1.4
mm) and lateral (0.6 ± 0.7 mm) to the alveolar bone crest.
The study clearly indicated the need for improvements in
the assessment of probing depth at molar furcation sites.
Eickholz (1995) investigated horizontal probing attach-
ment levels in a sample of 200 molars with a total of 506
furcation entries. Periodontal surgery was performed in a
1997
8(3)336-56 Crt Re Ora Bil Me
8(3)-336-356 (1997) Crit Rev Oral Biol Med
subsample of 127 teeth with 288 furcations. In these sites,
horizontal attachment level measurements were repeated
intrasurgically. A Nabers probe with 3-mm markings was
used for all determinations. Overall, pre-surgical mea-
surements slightly overestimated the extent of furcation
involvement in comparison with intrasurgically gathered
attachment levels, but the differences were statistically
significant only for class II furcations. To some extent, this
result is in contrast to the findings of Zappa et al. (1993),
who used similar methodology to determine the validity
of clinical furcation assessments. The researchers in
Zappa's study heavily overestimated the extent of furca-
tion involvement when using the furcation indices of
Ramfjord and Ash (I1979) or Hamp et al. (I1975), but missed
a high percent of class III furcations as verified intrasurgi-
cally. These authors concluded that clinical furcation
assessment is of poor accuracy.
In summary, the periodontal pocket is a three-dimen-
sional pathological structure that expands along a root
surface. It is delimited by the pocket epithelium, the root
surface, and a strand of junctional epithelium, which
forms the pocket's meander-like apical termination. The
periodontal examination is a clinician's effort to assess
such a pocket as accurately as possible. However, dis-
ease-related alterations of the periodontal tissues, and
anatomical peculiarities of the teeth, like furcation areas,
make periodontal probing an error-prone task. In general,
in the presence of inflammation, the probe tip penetrates
the base of the junctional epithelium and overestimates
pocket depth or attachment level. In the absence of
inflammation, however, the probe tip does not reach the
base of the junctional epithelium, resulting in pocket
depth or attachment level readings that are too small.
Therefore, presence or absence of tissue inflammation
can significantly affect probing measurements, and data,
especially change in probing depth or attachment level,
must be interpreted cautiously. In the next section, the
limits of periodontal probing will be explored further.
(IV) Assessment of Periodontal Tissues
The results of probing depth measurements are contin-
gent upon the probe tip diameter and shape, the probe
angulation, the force applied, and the location, presence,
or absence of inflammation in the subepithelial connec-
tive tissue. In other words, they are dependent on exam-
iner, probe, and subject (patient) factors. Most of the
published studies on probing have dealt with either
probe-related variables or the probe-periodontal tissue
interaction. In the following discussion, the pertinent lit-
erature is summarized.
(1) THE QUEST
FOR THE OPTIMUM PROBING FORCE
The problem of optimum probing force for the assess-
ment of probing depth or attachment level has been
343
Force (N)
0.5
0.4
0.3
0.2
0.1
O
Figure 2. Time-force diagrams characteristic of four periodontists. The curves were recorded on tape during probing sessions lasting 2 to
3 seconds, then replayed and analyzed. Note the large differences in maximum probing force. In (a), a defined probing force was main-
tained for a short period. In (b), the high initial probing force was followed by a period of force release. In (c), several short but very force-
ful attemxts were followed by a one-second probing movement of low force, and in (d), many probing attempts using various forces were
recorde
given a lot of thought, but a review of the pertinent liter-
ature quickly reveals that there is still no full agreement
on the subject. A first step in the right direction was made
when Gabathuler and Hassell (1971) contrived their pres-
sure-sensitive probe (Section 11/2). They used the probe in
a clinical experiment to determine probing force discrep-
ancies among experienced clinicians. Their instrument
was based on a ZIS probe with a tip diameter of 0.65 mm
and depth markings at 3, 6, and 9 mm. During the course
of the study, the investigators were able to identify four
probing force patterns, each typical for a different probing
technique. Some examiners placed the probe into the
gingival sulcus using a defined force, which then was
maintained for a short period until probe retraction (Fig.
2A). Other examiners inserted the probe with high initial
force, then, with rocking movements, directed the tip
mesially and distally within the sulcus while releasing
some force (Fig. 2B). In situations where it was more dif-
ficult to position the probe tip in the sulcus, the examin-
ers made several quite forceful initial probing attempts.
When entrance was gained, the probing force dropped
and was kept level for about one second (Fig. 2C). Some
clinicians applied a series of short probing bursts of vari-
ous strengths (Fig. 2D). It was not clear which of the prob-
ing techniques yielded the best results, but it was
observed that, in healthy individuals, probing forces
rarely exceeded 0.4 N. The highest average force regis-
tered for any of the eight examiners was 0.33 ± 0.12 N as
compared with the lowest average force of 0.20 ± 0.08 N.
The overall mean probing force was 0.25 ± 0.09 N, corre-
sponding to an average probing pressure of 0.75 N/mm2.
Ever since these results were published, gentle probing
344
d
-fInn
Aul '
IA
AA
a 2
seconds
has been associated with a probing force of 0.25 N!
In a subsequent study, Hassell et al. (1973) investi-
gated interexaminer differences among six periodontists
in five patients exhibiting adult periodontitis. The same
pressure-sensitive periodontal probe as in the previous
study was used. A statistically significant difference (p <
0.01) was observed among examiners, with a range from
2.95 mm to 3.52 mm for the average per-subject probing
depth. Very large differences in probing force were found
among the six examiners. Table 1 shows examiner mean
probing forces, probing pressures, and standard devia-
tions listed separately for shallow sites and periodontal
pockets. The mean probing forces applied by five out of
six examiners were much higher than the 0.25-N "gold
standard" as defined for gentle probing. For all examin-
ers, probing force was negatively correlated with probing
depth in deep pockets, whereas the correlation was pos-
itive for shallow pockets. The authors interpreted these
results to mean that even experienced clinicians probe
the often-painful deep pockets with much more caution
than they do the shallow sulcus of a healthy site.
At the time it was conducted, the research by
Gabathuler and Hassell (1972) and Hassell et al. (1973)
was quite advanced from a technological viewpoint.
Indeed, their research was well ahead of their time, and
the next significant contribution to the subject was not
published until 1978, when van der Velden and de Vries
(1978) introduced their constant-pressure probe (for a
detailed description, see Section 11/2). The major advan-
tage of their instrument was that it permitted pockets to
be probed by defined pressure, thus enabling the rela-
tionship between probing force and probing depth to be
Crit Rev
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TABLE 1
Mean Probing, Force and Probing Pressure
Standard Deviation of Six Examiners for Shallow and Deep Pockets
in Subjects with Slight to Moderate Periodontal Disease
Probing Pocket Depth 1 to 3 mm Probing Pocket Depth . 4 mm
Examiner n Force Pressure
A 90 0.43 ± 0.21 1.30 ± 0.63
B 90 0.48±0.17 1.45±0.51
C 87 0.51 ± 0.21 1.54 ± 0.63
D 76 0.45±0.11 1.36±0.33
E 80 1.07± 0.36 3.22 ± 1.08
F 90 0.23±0.11 0.69±0.33
Probing force and probing pressure are in Newtons and Newtons/mm2, respectively. Sample size n refers to the examined number of pockets.
(Modified from Hassell et al., 1973)
investigated. Eight subjects were enrolled in the first
study. They exhibited moderate to advanced periodonti-
tis, as diagnosed by alveolar bone loss of up to two-
thirds of the root length in the maxillary anterior seg-
ment. The subjects received a thorough dental cleaning
and subgingival scaling to remove deposits that could
interfere with probing. Following the treatment, the sub-
jects had no visible signs of marginal gingivitis. Two
series of measurements were performed. In the first
series, the probe, which had a tip diameter of 0.63 mm,
was used with increasing probing forces-namely, 0.15,
0.25, 0.50, and 0.75 N-equivalent to probing pressures
of 0.48 N/mm2, 0.80 N/mm2, 1.60 N/mm2, and 2.41
N/mm2, respectively. In the subsequent series of mea-
surements one week later, probing forces were applied in
reverse order. Probing forces > 0.75 N were too painful
for the subjects. The data disclosed a positive, linear
relationship between probing depth and probing force. A
separate analysis was performed on pockets which, when
assessed with 0.75-N probing force, were diagnosed with
4 mm or deeper probing depth. It was found that 63.3%
of those pockets were > 2 mm deeper than was assessed
with the 0.1 5-N probing force. The percentages for pro-
bing forces of 0.25 N and 0.5 N were 43.1% and 9.7%,
respectively. The largest probing depth difference
observed was 7 mm. The authors concluded from their
experiments that probing forces must be standardized to
improve reproducibility of probing measurements.
In a study using probing forces of 0.50 N, 0.75 N, 1.0
N, and 1.25 N, van der Velden (1979) investigated the
location of the probe tip in relation to the level of the
connective tissue attachment and alveolar bone. A sam-
ple of 20 subjects exhibiting advanced periodontal
destruction participated, including 13 subjects with teeth
that were treatment-planned for extraction, and seven
subjects who were scheduled for periodontal surgery.
Probing depth measurements were made by means of van
der Velden's constant-pressure probe. Reference marks at
8(3)336-356 (1997)
8(3):336-356 (1997)
n Force Pressure
29 0.49 ± 0.21 1.48 ± 0.63
28 0.36±0.16 1.08±0.48
33 0.59 ± 0.24 1.78 ± 0.72
41 0.48±0.16 1.45±0.48
37 1.27 ± 0.42 3.83 ± 1.27
25 0.25±0.15 0.75±0.45
the level of the gingival margin and staining of the con-
nective tissue attachment permitted determination of
probing depth after tooth extraction. In the surgery group,
the apical borders of restorations were used as the land-
mark for measurement of interproximal relative attach-
ment levels or relative alveolar bone levels during the flap
procedure. It was concluded that, for a probe diameter of
0.63 mm, the optimum probing force was 0.75 N, corre-
sponding to a probing pressure of 2.41 N/mm2. At this
force level, the tip of the probe was consistently located
at the most coronal connective tissue fibers.
Almost coincidentally, Robinson and Vitek (1979)
studied the relationship between probe tip location and
probing force using histological methods. Using a con-
trolled-force probe with a terminal tip diameter of 0.35
mm, they also evaluated the importance of gingival
inflammation in regard to probe tip penetration. Three
probing forces-0.196 N, 0.245 N, and 0.294 N-corre-
sponding to probing pressures of 2.04 N/mm2, 2.55
N/mm2, and 3.06 N/mm2, respectively, were investigated
on a sample of 51 teeth. The coronal level of the connec-
tive tissue attachment served as the landmark against
which the accuracy of probing was tested. In healthy tis-
sue, corresponding to a Gingival Index (GI) = 0, any of the
three probing forces led the probe tip to stop short of the
level of connective tissue attachment. In contrast, in
highly inflamed tissue, corresponding to a GI = 3, any of
the three probing forces was sufficient for the probe tip
to run past the critical landmark. Thus, the results of the
study underscored convincingly that probing force and
gingival inflammation are equally important determi-
nants of probe penetration.
Using the beagle dog periodontitis model and a con-
trolled-force probe with a tip diameter of 0.63 mm, van
der Velden and Jansen (1980) investigated the relation-
ship between a great variety of probing forces and probe
tip penetration. Forces used to place the wooden tips
were 0.15 N, 0.25 N, 0.50 N, 0.75 N, 1.00 N, and 1.25 N,
345
Crit Rev Oral Biol Med
Ci-it Rev Oral Bid Med
345
 corresponding to probing pressures of 0.48 N/mm2, 0.80
N/mm2, 1.60 N/mm2, 2.41 N/mm2, 3.21 N/mm2, and 4.01
N/mm2, respectively. Evaluation of probe tip location
was done on histologic sections. The placement of liga-
tures resulted in plaque accumulation, inflammation,
and periodontal pocket formation. In 21 of 23 specimens,
the investigators found an intact layer of pocket epitheli-
um between the tip and the connective tissue.
Connective tissue compression increased with increas-
ing probing force. With probing forces exceeding 0.75 N,
the tip location was always apical to the connective tis-
sue attachment level. In contrast to other studies
(Armitage et al., 1977; Spray and Garnick, 1979), no pene-
tration of the tip into the tissue was found, however.
Freed and co-workers (1983) used a pressure-sensi-
tive probe to analyze intra-examiner and interexaminer
probing force variations among clinicians with different
dental training, i.e., periodontists and periodontal resi-
dents, general dentists, dental hygienists, and senior
dental hygiene students. The probe tip end diameter was
a standard 0.35 mm, and the probe force sensor provid-
ed accurate probing force measurements between 0.05 N
and 1.37 N, corresponding to probing pressures of 0.52
N/mm2 and 14.24 N/mm2, respectively. A total of 45
healthy subjects participated in the study. All teeth
except third molars were assessed, and probing depths
were < 3 mm. A wide range of probing forces was mea-
sured among examiner groups, and inter- and intra-
examiner differences were assessed. Average minimum
probing forces were 0.17 ± 0.01 N for hygienists, 0.18 +
0.02 N for periodontists, 0.19 ± 0.03 N for general den-
tists, and 0.28 ± 0.04 N for dental students. The smallest
average maximum forces were observed for periodontists
and hygienists (0.55 ± 0.08 N, 0.59 ± 0.05 N, respective-
ly), followed by dental students (0.66 ± 0.07 N) and gen-
eral dentists (0.76 ± 0.09 N). A statistically significant dif-
ference in probing force was observed between anterior
and posterior teeth, but probing forces were indepen-
dent of age, gender, or handedness of the clinicians.
Robinson and Vitek (1979) presented data that
implied an almost direct linear relationship between
probing force and probe penetration. Furthermore, they
provided strong evidence that the tissue condition can
affect the relationship. Based on the results he obtained
with the pressure-sensitive probe, van der Velden (1979)
questioned the direct linear relation and proposed a
plateau level of probing depth if probing force is allowed
to exceed a critical value. Mombelli and Graf (1986)
responded to this challenge with the development of a
prototype probe that permitted the simultaneous mea-
surement of probing depth and probing force during
insertion into the pocket. Their probe was equipped with
a 0.5-mm-diameter tip, a piezoelectric force transducer,
and a linear position transducer. Because of inherent
drifting of the piezoelectric system, measurement within
346 Crit Rev Oral
Crit Rev Oral Biol
Biol Med
3 sec was mandatory in all experiments. Five untreated
patients diagnosed with periodontitis were enrolled in
the study. The first probings were made at the initial perio-
dontal examination. A therapy phase followed, including
oral hygiene instructions, scaling, and root planing. Six
weeks later, a second measurement was performed at
each site by means of a standard periodontal probe.
Depth-force recordings followed. They were made with
the special probe, at forces of up to 2.0 N. Several key
points were identified on the probing-force/depth plots.
First, the penetration depth at 1.2 N probing force was
marked. Next, the probing force b was determined. The
value b was defined as the minimal force required to get
a depth reading 0.5 mm less than the depth obtained
with 1.2 N. Changes in b, as a result of periodontal treat-
ment, were representative of changes in the mechanical
properties of the pocket tissues against probing. Depth-
force diagrams suggested an initial strong increase in
probing depth with increasing probing force, but that no
further progression in probing depth can be obtained
when probing forces are in excess of 1 N. The minimal
probing force b1, as determined before therapy, was sta-
tistically significantly smaller than the force b2 obtained
following therapy. Higher probing forces were necessary
after therapy for the same depth reading to be main-
tained. The data supported the concept that, before and
after therapy, the probe tip reaches different zones of the
pocket if an attempt is made to keep probing forces con-
stant. The decrease in probing depth could be the result
of the establishment of a long junctional epithelium, or
another epithelial attachment mechanism.
Besides standardized probing force, the selection of
an optimum probe diameter is equally important to
improve accuracy and precision of pocket probing. In
fact, from the above review, it is evident that periodontal
probes with a great variety of tip diameters have been
used, making the comparison and interpretation of pro-
bing studies even more difficult. The importance of the
optimum diameter choice, however, was not approached
scientifically until the late 1980s. In 1989, Keagle et al.
suggested that the foremost probe diameter would be
the one which best discriminates gingival health from
inflammation as determined by the statistically most sig-
nificant difference. To test the hypothesis, they used the
beagle dog model and induced various levels of gingival
disease or health by placing the animals on various
diets, by oral hygiene deprivation, and by affixing liga-
tures around test teeth. The force and probing data were
generated by means of a computer-controlled probing
system consisting of an electromechanical probe, a con-
trol box, an X-Y display, a line printer, and a console that
allowed data to be recorded. The probe tip was placed
perpendicular to the attached gingiva. Upon contact with
the gingival tissue, the device automatically advanced
the probe tip with a velocity of 0.1 mm/sec, increasing
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probing force until a resisting force of 1.0 N was reached.
Probe diameters of 0.4, 0.6, 0.7, and 0.8 mm were evalu-
ated. Readings were made at 0.05 N, 0.10 N, 0.20 N, 0.75
N, and 0.90 N. A probe diameter of 0.6 mm was found to
have the greatest discrimination power for gingival
inflammation vs. health. Garnick et al. (1989) used a sim-
ilar study design and the same probe type. They con-
cluded that a probing pressure of 1.06 N/mm2 would dis-
place the probe tip 0.1 1 mm apical to the base of the gin-
gival sulcus. Such a difference seemed clinically of little
relevance. More recently, Keagle et al. (1995) used their
electromechanical probe with a 0.6-mm diameter to
investigate, in the beagle dog model, the contribution to
probe resistance of the gingival tissues lateral to the sul-
cus. They found that the lateral gingiva offers resistance
to probe advancement only at probing pressures exceed-
ing 1.41 N/mm2. A probing pressure of 1.06 N/mm2, in
combination with a probe diameter of 0.6 mm, had the
least effect on probe advancement and probing variabil-
ity at different anatomical sites.
Atassi et al. (1992) investigated the effect of tine
shape on probing depth under constant probing force
(0.25 N) conditions. Reproducibility of probing depth
measurements with the parallel-sided tine (0 0.5 mm)
was slightly better than the one obtained when the
tapered tine with a similar tip end diameter was used. In
addition, there was a trend to larger probing depths
when measurements were executed with a probe with a
parallel-sided tine. Recently, Barendregt et al. (1996) con-
firmed the importance of tine shape for the assessment
of probing depth in a study that included 12 subjects
exhibiting moderate to severe periodontitis.
In the preceding section, it was shown that the tissue
status, i.e., inflammation or health, can affect probing
measurements greatly. In this section, the importance of
probing force and probe characteristics was elucidated.
The pertaining literature is abundant, but its interpreta-
tion is hampered by the obvious lack of agreement of what
may constitute the best combination of probing force and
probe design. The ideal probe should allow for valid pro-
bing measurements with minimal measurement error.
(2) REDUCING MEASUREMENT ERROR
(2.1) Systematic error
Measuring a distance, e.g., probing depth or attachment
level, means comparing it with a known-length unit
defined as a "millimeter". The objective of this interval
scale measurement is to determine as accurately and
precisely as possible how many such units the measured
distance contains. However, measurement is inevitably
subject to error, which must be determined and reported
for any experimental study. If a trained examiner mea-
sures the depth of a deep periodontal pocket to the near-
est millimeter and then repeats the measurement one
8(3)336 356 (1997) Grit Rev
8(3):336-356
Crit Rev Oral Biol Med
day later, experience shows that the two results will not
be identical. Since the depth of a pocket does not mea-
surably change over a period of a day, the discrepancy
must be due to measurement error. Sources of error may
be the instrument used for measuring, the measurement
technique, the examiner, and/or the examined object. It
is important to know the size of this error.
Measurement error includes both systematic and
random components, but this partitioning is somewhat
unsatisfactory because, in practice, it is often necessary
to regard bias as random (Healy, 1989). For reasons
explained in Section III, the true depth of a periodontal
pocket is not known, and the measured distance is there-
fore called "probing depth". In theory, repeated determi-
nations of probing depth should result in an average that
coincides with pocket depth. However, there is over-
whelming evidence that, even after many repetitions,
mean probing depth does not approach pocket depth.
Therefore, probing depth measurements must be consid-
ered biased observations. The term accuracy refers to the
presence or absence of measurement bias.
Systematic error may lead to constant or progressive
over- or underestimation. It is often difficult to detect but
can be greatly reduced by careful planning and by
improving the instruments. For example, the introduc-
tion of controlled-force probes was an important step
toward reduction of bias. Further improvement was
achieved by the development of the third-generation
periodontal probes, which allow for unbiased electronic
data capturing. The operation of measuring a distance,
e.g., reading a millimeter value from the markings of the
periodontal probe, can be associated with a digit prefer-
ence error. For example, the periodontal probe with
Williams markings allows for precise readings at 1, 2, 3,
5, 7, 8, 9, and 10 mm, but markings at 4 and 6 mm are
missing. Examiners using this instrument tend to bias
their readings toward an odd number, especially 5 mm, if
the measured value falls anywhere between 3 and 7 mm.
Such bias can be corrected if the examiner is made aware
of it, or completely eliminated by the use of probes with
markings at each millimeter or by electronic data captur-
ing and digital read-out. In addition, the millimeter
markings on periodontal probes are not always accurate
(Winter, 1979). Van der Zee et al. (1991) were able to show
that even if probes exhibited identical design and were
made by the same manufacturer in the same production
line, identical probe markings could not be ensured.
They observed deviations that could have led to a mea-
surement error of up to 1 mm, assuming that the read-
ings were made to the nearest marking.
(2.2) Random error
In contrast to systematic error, random error is not pre-
dictable and varies around the true measurement value.
Such variation is usually referred to by precision. Random
347
347
Oral
Biol
error can be estimated from the data obtained in dupli-
cate (or multiple) measurements. However, duplicate
measurements are time-consuming for the examiner and
often painful for the patients. While they are a normal
procedure in clinical research, they are not standard in
dental practice.
If a single examiner makes duplicate measurements
on n independent probing sites, the method error SM
expressed as standard deviation with n degrees of free-
dom can be easily assessed from:
SM = 1\ * XSdE2(1)
2n (1)
where di denotes the differences between duplicate mea-
surements at site i, and similar repeatability and bias for
each site are assumed. The same numeric value can also
be obtained from a one-way analysis of variance (Fleiss
and Kingman, 1990; Kingman et al., 1991). In periodontal
probing, when duplicate probings are executed within a
short period of time, the second measurement is usually
biased toward a greater value than the first. The term
n measurement variation and deep pockets or sites
Fd
, dI2
in formula (1) must then be corrected by a factor ($d)2/n
(Snedecor and Cochran, 1967) for the possible systemat-
ic difference between the first and second probing
rounds, and the factor 2n should be replaced by 2(n-1).
Note that the correction implies a reduction of the
degrees of freedom by one. For manual probes, published
method errors for a single probing depth measurement
range between ± 0.30 mm and ± 0.70 mm (Glavind and
Loe, 1967; Haffajee et al., 1983; Goodson, 1986; Gibbs et
al., 1988; Osborn et al., 1990, 1992; Fleiss et al., 1991).
In essence, what was said for probing depth pertains
also to attachment level determinations, but note that
the manual attachment level assessment includes two
measurements, i.e., the distance from the probe end to
the gingival margin and that from the CEJ to the gingival
margin. Of course, both measurements are subject to
measurement error, and the error of the attachment level
measurement is equal to the sum of the individual mea-
surement errors. Thus, it can be predicted that a manual
attachment level measurement will be subject to a mea-
surement error usually equal to or greater than the error
of the probing depth measurement alone. The combined
error for a single attachment level measurement was
reported to range between ± 0.40 mm and ± 0.90 mm
(Glavind and Loe, 1967; Badersten et al., 1984; Fleiss et al.,
1991; Osborn et al., 1990, 1992). These values are indeed
somewhat greater than those obtained for probing depth.
If replicate probing depth or attachment level mea-
surements are made by two or more examiners instead of
348 Crit
Crit Rev
Rev Oral
Oral Biol
Biol Med
a single examiner, a larger variation can be expected.
Formula (1) does not apply, and statistical models
including subject, site, examiner, interaction, and error
components must be constructed and analyzed by vari-
ance component analysis. Recently, Fleiss and Kingman
(1990) presented a detailed example of a simple reliabil-
ity study including three examiners and 10 subjects. It
was based on whole-mouth averages as the statistical
unit and used a two-way analysis of variance and subse-
quent variance component analysis for the estimation of
measurement error and intraclass correlation coefficient.
Fleiss et al. (1991) contributed a slightly different
approach. They used a sample of 20 subjects with
untreated moderate to severe periodontal disease. All
sites were examined twice in random order by three
examiners, i.e., a periodontist, an epidemiologist, and a
prosthodontist with little periodontal experience. The
investigators computed patient- and site-specific
interexaminer variances by averaging the two measure-
ments by each examiner and then calculating the vari-
ance of these three averages. The authors identified
pocket depth as clearly the most important source of
exhibiting large attachment levels as the most difficult to
repeat. Best reproducibility for both probing depth and
attachment level was observed for the epidemiologist
who was trained in collecting data in a highly repro-
ducible way. In contrast, periodontists focus their train-
ing toward the identification of sites with the "greatest
degree of disease".
Thus far, the discussion of method error was limited
to studies that were performed with first-generation
probes. By and large, what was said about manual
probes also holds true for electronic probes. In fact, a
great many studies were undertaken to determine the
method error of second- and third-generation probes
(Hassell et al., 1973; van der Velden, 1978; van der Velden
and de Vries, 1980; Watts, 1987, 1989; McCulloch et al.,
1987; Gibbs et al., 1988; Goodson and Kondon, 1988;
Magnusson et al., 1988a,b; Osborn et al., 1990, 1992;
Becherer et al., 1993; Tupta-Veselicky et al., 1994; Wang et
al., 1995; Mayfield et al., 1996). Single measurement
errors between ± 0.2 mm and ± 1.0 mm were reported.
However, any comparison of probe performance must be
carried out prudently, because experimental conditions
may vary greatly from experiment to experiment. The
main features of electronic probes are the constant prob-
ing force, electronic data collection, and the potential for
high precision in the execution of measurements. While
such characteristics reduce measurement bias and pos-
sibly also the number of outliers (see Section IV/3), they
do not necessarily translate into smaller random error
(variability).
The sample data depicted in Fig. 3 were generated by
two examiners using the Florida Stent Probe® in a study
8(3):336-356
Med 8(3):336-356 (1997)
of relative attachment level measure- 125
ments under ideal clinical condi- Rellative Attachment Levels
tions. Repeated measurements were
taken on a sample of 479 periodontal
sites in healthy subjects. There was a
30-minute break between the two 100 -
measurement rounds of each appoint-
ment and a three-week gap between
the two appointments. Each examin-
er probed each subject once per ap-
pointment. Examiner 1 was the first
examiner at appointment one, and
Examiner 2 was first at the second a)
appointment. The averages of the re- v
peated measurements were used for 2 50 -
data presentation. Superimposed on
the histogram is the Gaussian curve
for a normally distributed sample
N(y, or2) with mean i and variance or2
as obtained from the original data set. 25 -
The histogram and Gaussian curve are
both centered at x = 0.12 mm, indi-
cating that, on average, Examiner 1
generated slightly but statistically
significantly larger values than Exa- °
=-II
miner 2 (p < 0.001, paired t test). The
variation is s2 = 0.2376 mm2, and the -2.5 -2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0 2.5
single measurement error ± 0.34 mm. Measurement Error (mm)
This value is of the same magnitude
as data obtained by other researchers Figure 3. Frequenccy distribution of differences between duplicate measurements of relative
(Clark et al., 1993) in similar studies. attachment level. SSuperimposed is a normal curve with characteristics p = 0.12 mm and
Note the match of the frequency dis- = + O0.48 mm.
tribution of measurement errors with
the Gaussian curve computed based on theory. defined by Hamp et al. (1975) or other furcation classifica-
A comprehensive study of the sources of variation of tion systems. Only few investigators have attempted to
relative attachment level measurements was carried out estimate the probing error of furcation measurement.
by Yang et al. (1992) using the electronic Florida Stent Eickholz (1995) used the color-coded Nabers probe with 3
Probe®. They tested four study designs to investigate mm markings and found single measurement errors of ±
effects of instrument error, position error, short-term vari- 0.88 mm, + 0.66 mm, and + 0.68 mm for class 0, class I,
ation, and long-term variation on relative attachment and class II furcations, respectively. The same author also
level measurements in healthy subjects and patients with computed single measurement errors for vertical attach-
gingivitis or periodontitis. Single measurement errors of ment levels in a subset of 11 subjects with 109 furcations.
± 0.20 mm, ± 0.25 mm, and ± 0.31 mm were observed in These measurements were performed by means of a PCP-
the healthy, gingivitis, and periodontitis groups, respec- UNC 15 probe with millimeter markings. Single measure-
tively. A breakdown of the error variation into the model- ment errors were ± 0.58 mm, + 0. 56 mm, + 1. 16 mm, and
relevant components revealed that error size increased ± 0.53 mm for class 0, class I, class II, and class III furca-
with severity of disease, and instrument error accounted tions, respectively. judging by the little information that
for a large part of total variation, especially in periodonti- is available on furcation assessment, it seems that the
tis patients. Unfortunately, similar data are still not avail- method error of horizontal and vertical furcation probing
able for manual probes. is of similar magnitude when the measurements are exe-
The assessment of horizontal and vertical attachment cuted by experienced examiners.
levels in furcation areas is impaired by tooth/root mor-
phology, i.e., difficult probing access. Clinically, horizontal (3) CONSISTENCY BETWEEN MEASUREMENTS
attachment loss in furcation areas ("furcation involve- Consistency can be defined as the agreement of two
ment") is usually diagnosed based on four classes as quantitative measurements if it is assumed that neither

8(3) 336-356 (1997)

8(3)-.336-356 Crit
Crit Rev Oral Biol
Rev Oral Med
Bid Med 349
349
 ship between the measurement
2
error variance and the variance of
the characteristic under investiga-
d +3.1s + tion can be used for the assess-
CN
a)
.-
ment of examiner agreement or
E
xc
1 - *.0.00
* 0 consistency. The statistic is known
d@ t% * A % as the intraclass correlation coeffi-
0 0 cient (ICCC). The use and interpre-
E
O -
tation of various ICCCs have been
a)
Cu exhaustively covered in several
E articles (e.g., Fleiss and Kingman,
wLx -1 W 0 1990; Dunn, 1992; Muller and
d-3.1sM
M
Buttner, 1994). Osborn et al. (1990,
1992) published numerous ICCC
-2 3 4
I I 6 -.-, 8 .
9 .
values for periodontal probing and
2 3 4 5 6 7 8 9 10 attachment level measurements.
(Examiner 1 + Examiner 2) / 2 These values were obtained from
(in mm) reliability studies conducted in a
healthy population and in a popu-
lation with moderate to advanced
Figure 4. Difference against mean plot of the data from the relative attachment level cornsis- periodontitis. Two types of the
tency study. Also depicted are upper and lower limits of agreement, mean difference (biias), electronic Florida Probe® and the
and the linear regression line for examination for trend. The presented data suggest g ood University of Michigan 'O' Probe
agreement between the two examiners. A small bias d = 0.12 mm was identified, indicaiting resulted in ICCCs between 0.41 and
that, on average, measurements by Examiner 1 were slightly larger than those obtainecI by
Examiner 2. Furthermore, the bias increased with increasing probing depth. Outliers are eas- 0.90, indicating fair to very good
ily identified as points outside the area of agreement defined by d ± 3.1 SM. agreement. Kingman et al. (1991)
determined consistency of repeat-
ed examinations carried out under
of the two measurements is the gold standard. This is field conditions and in dental college facilities. Perio-
often encountered in calibration studies of periodontal dontal probes with Williams markings and a 0.6-mm tip
disease where the observations of two or more examin- diameter were used at both sites. The ICCC calculations
ers are compared, and true pocket depths or attachment were based on whole-mouth averages. Regardless of the
levels are unknown. The use of linear regression tech- quite different clinical conditions, attachment level mea-
niques for the study of examiner agreement is common surement consistency was high. Surprisingly, it was bet-
in clinical research. But linear regression analysis is not ter in the field (ICCC = 0.98) than under clinical condi-
appropriate if both variables (examiners) are subject to tions (ICCC = 0.81). These publications show that well-
error. Furthermore, Pearson's product moment correla- trained examiners can reach a high degree of consisten-
tion coefficient r measures how far each observation de- cy even if probings are conducted under clinically diffi-
viates from the best-fit line. Therefore, r is a measure of cult conditions. For the data presented in Fig. 3, the ICCC
association between two variables but does not provide was 0.91, attesting to good interexaminer consistency.
information on agreement. For example, an almost per- While it is convenient to express the result of a con-
fect correlation (r 1) may result if one examiner obtains sistency study by a single measure, its interpretation
probing depths that are about twice as large as the mea- may leave many unanswered questions. In such situa-
surements of the second examiner. Of course, in such a tions, visual presentation of the data is sometimes help-
situation, agreement between the two examiners would ful. An excellent alternative was presented by Altman
be poor. Good agreement between examiners is ob- and Bland (1983), who proposed to plot the differences
served only when the pairs of measurements closely fol- of the observed pairs of measurements against the aver-
low the line of concordance (examiner A = examiner B). ages of the pairs. Agreement can be assessed based on
When two examiners are compared in a study of the bias estimated by the mean difference d and the stan-
attachment level (or probing depth) reproducibility, nei- dard deviation sD of the differences. Then, an area of
ther of the two contributes the true measurements. acceptable agreement can be defined by the upper and
Instead, the degree of agreement between the examiners lower limits of agreement, which can be set at ± 2 * SD as
must be determined. It is assumed that each probing suggested by Altman and Bland (1983; Method A), or at
measurement consists of two parts, the true attachment ± 3.1 * sM, as proposed by Namgung and Yang (1994;
level g plus the error component E. Then, the relation- Method B) for outlier identification using the option-3

350 Grit Rev Oral Biol

Crit Rev Oral Biol Med 8(3):336-356 (1997)
TABLE 2
Landis and Koch's (1977) Criteria for the Interpretation of the Kappa Statistic
kappa (K) 0.00 0.01-0.20 0.21-0.40
Agreement no s ight fair
scheme (Section IV/4). Here, sM denotes the single mea-
surement error. Examination for trend can be accom-
plished by including the regression line. Fig. 4 illustrates
this approach using our data set. Note that bias d (0.12
mm) and standard deviation SD (± 0.49 mm) are the same
in Figs. 3 and 4.
If repeated measurements on the same sites are per-
formed by each examiner, the size of the standard devia-
tion of the differences is underestimated. Then, the cor-
rected standard deviation sC (Altman and Bland, 1983) is
calculated as
(2
sc='D +12
S 1 2 setting. Their weighted kappa combined pairs of attach-
4 4 2
with SD representing the standard deviation of the differ-
ences between the means for each method and sp, and s2
denoting the standard deviations of differences between
repeated measurements for each method separately. The
value pairs for the agreement limits in our example are
1-1.095 mm, 1.338 mmi and 1-1.211 mm, 1.455 mmi by
Methods A and B, respectively. Linear regression analy-
sis indicated a positive trend for the association between
examiner differences and means. The trend was statisti-
cally significant at the 0.005 level.
The non-parametric Cohen's kappa (K; Cohen, 1960)
statistic is a frequently used measure of interexaminer
agreement for categorical data. Kappa can fall between 0
and 1, with values near 0 indicating agreement no better
than would be expected by chance and 1 indicating per-
fect agreement. It was first applied in periodontal
research by Fleiss and Chilton (1983). The squared
weighted kappa is the approximate equivalence of the
ICCC (Cohen, 1968; Fleiss and Cohen, 1973; Krippendorff,
1970). For the determination of kappa, the chance
expected proportion of agreement pC and the overall pro-
portion of agreement po between the two examiners must
be calculated. Then, kappa is determined from:
K = Po Pc
I - P,
Kappa is associated with a standard error, which can be
used for the testing whether the measure differs from
zero or for the construction of confidence intervals.
According to Cohen (1960), the standard error of kappa
1997
56
8(3)336 Crt Re Ora Bil Me
8(3):336-356 (1997) Crit Rev Oral Biol Med
0.41-0.60 0.61-0.80 0.81-1.00
moderate substantial almost perfect
oKcan be computed as:
K= Po ( l po)
N(1 -p)2
The proportions po and pC are defined as above, and N is
the sample size. Landis and Koch (1977) have provided
six categories for the interpretation of kappa (Table 2).
Kingman et al. (1991) applied the unweighted and
weighted kappa statistic to the study of intra-examiner
agreement in the determination of attachment levels
under field conditions and in a dental college clinical
ment level scores within ± 1.0 mm of each other.
Moderate overall agreement was observed under both
experimental conditions (K = 0.46), whereas weighted
kappa indicated excellent agreement to within ± 1 mm
(KW = 0.89 for dental clinic facilities; KW = 0.82 for field
conditions). The data set described in Section IV/2.2 and
depicted in Fig. 3 illustrates the use of the kappa statis-
tic for measuring examiner agreement in a study where
the Florida Stent Probe® was used. The original (contin-
uous) data as generated by each examiner were arranged
into six categories, i.e., category 1, < 4.00 mm, category 2,
4.01 to 5.00 mm, ... category 6, > 8.00 mm. Then, a cross-
table was constructed and kappa computed. A kappa
(± SE) of K = 0.568 ± 0.029 indicated only moderate
agreement between the examiners.
Moderate to excellent consistency was reported for
the assessment of horizontal attachment loss in furca-
tion entrances. Eickholz and Staehle (1994) obtained KW
values of 0.706, 0.944, 0.814, and 0.776 for distolingual,
mesiolingual, lingual, and buccal furcations of 100 first
and second molars in 25 subjects with moderate to
severe periodontitis. However, a high degree of chance-
expected agreement (0.801 < Pe > 0.940) was reported for
these results. They should be interpreted cautiously,
because high chance-expected agreement leads to kappa
estimates with large standard errors, as can be easily ver-
ified by means of the formula for o-K
(4) IMPROVING DATA QUALITY
In clinical research as well as in practice, we use mea-
surements to aid us in making correct decisions. We
measure a periodontal site of a patient to decide, e.g.,
whether the site is diseased, or whether surgical therapy
35
351
is indicated. Certainly, we are also interested in knowing
whether the therapy was successful. But measurements
are meaningful only within certain limits of uncertainty
as determined by the magnitude of the measurement
error. A reduction of the measurement error can be
achieved in many ways, but data quality improvement is
also a function of costs. Therefore, measurement error
should be reduced to that point only, when the costs
accrued for the gaining of precision and accuracy balance
with the costs that accrue by the making of wrong deci-
sions (Healy, 1989). In the same context, it is important
to eliminate measurement outliers, because they are
especially damaging to the data quality, possibly leading
to false and often costly decisions. Second- and third-
generation probes are a good example, for they strive to
make probing measurements better by the use of
improved technology. An example of methodology
improvement is the taking of repeated measurements of
all sites. However, it seems that even under carefully con-
trolled experimental conditions and with sophisticated
instruments, some outliers persist (Janssen et al., 1987;
Best et al., 1990; Clark et al., 1993; Namgung and Yang,
1994). In general, an outlier is defined as a measurement
error that is beyond the explanation of random error
(Yang et al., 1992). Several authors have suggested a
probing scheme that allows outliers to be detected and
eliminated (Gunsolley and Best, 1988; Marks et al., 1991;
Osborn et al. 1990, 1992). The scheme, called "option-3"
(Clark et al. 1993), uses two probings per site and evalu-
ates how well the two measurements agree with each
other. If the difference between the measurements
exceeds a threshold value, a third measurement is taken.
Two questions are eminent with respect to this proce-
dure: What is the optimum threshold that triggers the
use of option-3? and, What is the appropriate estimate of
the measurement for a site that needs option-3 adjust-
ment? Namgung and Yang (1994) approached the first
question using least-squares estimates and extensive
simulation based on real-life data. They estimated the
mean of the target site by averaging the closest two of
the three values. The threshold was found to be propor-
tional to the measurement error, with the optimal value
at 3.10*ur. With the probing errors for single measure-
ment listed in Section IV/2, the threshold range for
attachment level measurement is 1.2 mm < Idl > 2.8 mm.
For our example of probing measurement consistency
(Fig. 3), the threshold was calculated to be 1.33 mm. This
means that the option-3 scheme would have detected 8
outliers among 479 duplicate measurements, corre-
sponding to a low "outlier" rate of 1.67%. A much higher
outlier rate must be anticipated in subjects with moder-
ate to severe periodontitis (unpublished observations).
Repeated measurements should be standard proce-
dure in clinical research. To ensure measurement inde-
pendence, the two probings must be well-separated.
352 Grit Rev Oral
Crit Rev Oral BioI
Biol Med
Yang et al. (1992) have suggested that the two probings
be strictly separated by completing the first round and
then performing the second round after subjects take a
five- to 10-minute break and use a mouthrinse. Of
course, repeated measurements are associated with
increased costs. However, repeated measurements are a
worthy investment, because they permit the investigator
to (1) increase measurement precision, (2) screen for
potential outliers, and (3) estimate a method error. All of
this will lead to increased statistical power or reduction
in sample size. Option-3 is a simple scheme for the fur-
ther improvement of data quality by substitution of a
third measurement for a possible outlier and use of the
average of the closest two measurements for estimation
of a mean. Other possibilities for outlier substitution are
conceivable, but with few exceptions (Janssen et al., 1988;
Namgung and Yang, 1994) they have not been investigat-
ed in detail, to date. They include the average of the
three measurements, the median, the geometric mean,
and the largest of the three values.
(V) Conclusions
Periodontal probing is a physical method to collect data
about the relation of the sulcus (pocket) bottom with
respect to a reference line, i.e., the gingival margin, the
CEJ, or any reproducible structure close to the measure-
ment site. The method is more than a century old and,
over the years, has seen little change in its principle.
However, major progress has been noted in three areas.
First, a series of experiments has led to a precise descrip-
tion of probe tip penetration relative to the apical termi-
nation of the junctional epithelium. Several modulating
factors of tip penetration have been identified, with
probing force, probe design, probe angulation, pocket
depth, and degree of inflammation being the most
important. Second, in the past two decades, two genera-
tions of new periodontal probes were developed. They
allow for controlled probing forces and higher instru-
ment precision. Electronic data-capturing virtually elim-
inates data transcription errors. Third, in the past
decade, statistical methods were developed (DeRouen et
al., 1995) for the improvement of the data structure, the
detection of disease progression, and disease modeling.
All together, a tremendous amount of knowledge on
probing has accrued over the years, and knowledge
transfer from research to practice is imminent.
However, it should not be overlooked that rather little
improvement has been made with regard to the probing
procedure per se. As a consequence, the measurement error
of electronic probes is not substantially lower than that of
manual probes. The precise location of the probe tip dur-
ing the probing event remains an enigma. Finally, our
patients continue complaining about the pain that prob-
ing inflicts (Heft et al., 1991). No doubt, there is a need for
alternatives!
Med
8(3):336-356
8(3):336-356 (1997)
 Acknowledgments
I would like to thank Drs. Ingvar Magnusson and Mark Yang for crit-
ical manuscript review and inspiring discussions. Ms. Janice Braddy
and Alexandra Hefti were of invaluable help in the preparation of the
manuscript. Special thanks go to Dr. Max 0. Schmid, Olten,
Switzerland. His doctoral thesis was an invaluable source of information
during the preparation of "Section II. A Short History of Periodontal
Probes'.
REFERENCES
AAP (1992). The American Academy of Periodontology
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Academy of Periodontology.
Altman DG, Bland 11 (1983). Measurement in medicine:
the analysis of method comparison studies. The
Statistician 32:307-317.
Armitage GC, Svanberg GK, Loe H (1977). Microscopic
evaluation of clinical measurements of connective
tissue attachment levels. J Clin Periodontol 4:173-190.
Atassi F, Newman HN, Bulman JS (1992). Probe tine
diameter and probing depth. J Clin Periodontol 19:301-
304.
Badersten A, Nilveus R, Egelberg 1 (1984).
Reproducibility of probing attachment level measure-
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