UnitFourteenCLINICALFEATUREOFCHRONICPERIODONTALDISEASEChronicgingivitisThemanifestationsofgingivalinflammationvaryconsiderablybetweenindividualsandfromonepartofthemouthtoanother.Thisvariationreflectstheaetiologicalfactorsatworkandthetissueresponsetothesefactors.Thisresponseisessentiallyamixtureofinflammationandfibroustissuerepair.Whentheformerpredominates,signsandsymptomsaremoreobvious;whenthefibroustissuecomponentpredominates,clinicalmanifestationscanbemuchmoresubtleandrecognizedonlybycarefulexamination.Inmakingadiagnosisitisimportanttokeepinmindtheappearanceofhealth,departuresfromwhichmayindicatedisease.Clinicalfeaturesare:l.Alteredgingivalappearance.2.Gingivalbleeding.3.Discomfortandpain4.Unpleasanttaste5.Halitosis.AlteredgingivalappearanceChangesinappearanceareusuallydescribedaccordingtocolor,shape,size,andsurfacecharacteristics.Healthygingivaearepalepinkandthemarginisknifeedgedandscalloped;astreamlinedpapillaisoftengroovedbyasluice-wayandtheattachedgingivaisstippled.Becausetheinterdentalembrasureisthesiteofgreatestplaquestagnationgingivalinflammationusuallystartsintheinterdentalpapillaandspreadsaroundthemargin.Asthebloodvesselsdilatethetissuebecomesredandswollenwithinflammatoryexudate.Theknife-edgedmarginbecomesrounded,theinterdentalsluice-wayislostandthesurfaceofthegingivabecomessmoothandglossy.Asthegingivalfibertheinflammatoryprocessthegingivalcufflosestoneandcomesawayfromthetoothsurfacesothatashallowpocketisformedbreaksupbundles.Iftheinflammationbecomesmorediffuseandspreadsintotheattachedgingivathestipplingdisappears.Ifinflammationissevereitcanspreadacrosstheattachedgingivatothealveolarmucosaandsoobliteratethenormallywell-definedmucogingivaljunction.Usuallythemostpronouncedinflammatoryswellingisseeninadolescentsandyoungadultssothatfalsepocketingisformed.Itiscalledfalseasopposedtorealorperiodontalpocketingwhichisformedbyapicalmigrationofthecrevicularepitheliumastheperiodontalligamentisdestroyedbyinflammation.Whereseveralaetiologicalfactorscombine,e.g.plaquedepositionpluslackoflip-sealplustheendocrinalchangesofpuberty,gingivalswelling,especiallypapillaryswelling,canbepronounced.Ifplaqueirritationislongstandingandlowgrade,themaintissuereactionwillbefibroustissueproductionsothatthegingivamayremainfirmandpinkbutbecomethickenedandloseitsstreamlinedshape.GingivalbleedingGingivalbleedingisprobablythemostfrequentpatientcomplaint.Unfortunatelygingivalbleedingissocommonthatpeoplemaynottakeitseriouslyandevenbelieveittobenormal;however,unlessbleedingobviouslyfollowsanepisodeofacutetrauma,bleedingisalwaysasignofpathology.Itoccursmostfrequentlyontoothbrushing.Bleedingmaybeprovokedbyeatinghardfood,apples,toast,etc.Whengingivaeareextremelysoftandspongy,bleedingcanoccurspontaneously.Bloodmaybetastedbythepatientandmaybesmeltonthepatient'sbreath.Ifthetissueresponseisfibrousovergrowth,thereisnobleedingevenwithvigoroustoothbrushing.DiscomfortandpainTheseareuncommonfeaturesofchronicgingivitisandthisisprobablythemainreasonforthediseasesbeingoverlooked.Thegingivaemayfeelsorewhenthepatientbrusheshisteethandbecauseofthishebrushesmorelightlyandlessfrequentlysothatplaqueaccumulatesandtheconditionisperpetuated.Thisrelativeabsenceofpainisoneofthesymptoms,whichdifferentiatesachronicgingivitisfromanacuteulcerativegingivitis.UnpleasanttastePatientsmaynoticethetasteofblood,particularlyiftheysuckataninterdentalspace.Unfortunatelythesensesarequicklybluntedandadisagreeabletasteisarelativelyinfrequentcomplaint.Halitosis‘Badbreath'frequentlyaccompaniesgingivaldiseaseandisacommoncauseofavisittothedentist.Thesmellderivesfrombloodandpoororalhygieneandmustbedistinguishedfromsmellsfromdifferentsources.Halitosishasanumberofcauses,bothintra-oralandextra-oral.Oraldiseaseandresidualfooddeposits,especiallythoseofavolatilenaturesuchaspeppermint,garlic,curry,etc.,representthemostcommoncauseofhalitosis.Pathologyoftherespiratorytract,nose,sinuses,tonsilsandlungscancauseanembarrassingsmell,ascandiseaseofthedigestivetract.Someitemsofdiet,e.g.garlic,areabsorbedbytheintestines,takenintotheintestinalbloodstreamandfinallyexhaledbythelungssothattheycanbesmeltalongtimeaftertheyhavebeeneaten.Mouthodouriscommononwakingandbetweenmeals,whenitisassociatedwithfoodstagnationandreducedsalivaryflow.Metabolicdiseases,diabetesanduraemiagivecharacteristicsmellstothebreath.Halitosiscanincreasewithage.ChronicperiodontitisTheclinicalfeaturesofchronicperiodontitisare:1.Gingivalinflammationandbleeding2.Pocketing3.Gingivalrecession4.Toothmobility5.Toothmigration6.Discomfort7.Alveolarboneloss8.Halitosisandoffensivetaste.Ofthisonlypocketingandalveolarbonelossareessentialfeaturesofchronicperiodontitis.GingivalinflammationandbleedingAlthoughgingivalinflammationisanecessaryprecursortoperiodontitis,obviousmanifestationsofinflammationbecomelessapparentwiththeprogressofperiodontitis.Frequentlythegingivaearepinkandfirm,thecontoursmaybealmostnormal,thereisnobleedingoncarefulprobingandthepatientdoesnotcomplainofbleedingonbrushing.Itisasthoughwiththedevelopmentofthepocketthediseasehasgoneunderground.Thepresenceandseverityofgingivalinflammationdependsuponoralhygienestatus;wherethisispoor,gingivalinflammationisevidentandbleedingofbrushing,orevenspontaneousbleeding,isnoticedbythepatient.Whenthepatient'stoothbrushingisgoodenoughtocontrolplaquebutwheresubgingivaldeposits,becauseofinadequatescaling,persist,thepresenceofperiodontaldiseasemaynotbeapparentonsuperficialexamination.Ifacarefulhistoryistakenmanysuchpatientsreportahistoryofpastbleedingwhichstoppedwhentheirtoothbrushingtechniqueimproved.Periodontaldestructionintheaverageadultistheproductofpastneglect,nottheresultofpresentoralhygienehabits.PocketingPocketmeasurementisanessentialpartofperiodontaldiagnosisbutmustbeinterpretedtogetherwithgingivalinflammationandswellingandradiographicevidenceofalveolarboneloss.Theoretically,ifthereisnogingivalswellingapocketover2mmdeepindicatessomeapicalmigrationofcrevicularepitheliumbutinflammatoryswellingissocommonespeciallyintheyoungerindividualthatpocketingof3-4mmmaybeentirelygingivalor‘false’.Pocketingof4mmislikelytoindicateanearlychronicperiodontitis.Theprecisemeasurementofpocketsisdifficultbecause:1.Probingthepocketcanbeuncomfortableandevenpainfulifthereisfrankinflammation.2.Pocketdepthisextremelyvariablearoundatooth.Interproximalpocketingisusuallydeepestbecausethatisthesiteofgreatestplaqueaccumulation,whilepocketingonthefacialaspectofthetoothisusuallymostshallowasthisiswherethetoothbrushmakesthegreatestimpactandmayevenproducegingivalrecession.Thismeansthatfourormoremeasurementsmayberequiredoneachtoothtogiveanaccuratepicture.3.Wherepresentoralhygieneisgoodthegingivalcuffmaybesotightaroundtheneckofthetoothastoresisttheinsertionofanordinaryperiodontalprobewithoutcausingpain.Themeasurementofpocketsinanaesthetizedtissueoftenproducesquitedifferentresultsfrompreviousmeasurementmadeinsentienttissue.4.Toothcontourandangulation,subgingivalcalculusorrestorations,aswellascariouscavities,mayimpedetheinsertionoftheprobe.Therearemanydesignsofpocket-measuringprobe,someof,whicharetoothicktoprovideaccuratemeasurementandsomeofwhicharesharpsothatthetissueispenetratedunlessgreatcareistaken.Ithasbeenshownthatpocketsofover3mmaremeasuredwithdiminishingreliability,anditisunfortunatethatmuchperiodontalresearchisbaseduponsuchanunreliablecriterion.Sometimesapurulentdischargecanbeexpressedfromthepocketbypressureonthepocketwall.GingivalrecessionGingivalrecessionandrootexposuremayaccompanychronicperiodontitisbutarenotnecessarilyafeatureofthedisease.Whererecessionoccurspocketdepthmeasurementisonlyapartialrepresentationofthetotalamountofperiodontaldestruction.ToothmobilitySometoothmobilityinalabiolingualplanecanbeelicitedinhealthy,single-rootedteeth,especiallylowerincisors,beingmoremobilethanmultirootedteeth.Increasingtoothmobilityisproducedby,l.Spreadofinflammationfromthegingivaintothedeepertissues2.Lossofsupportingtissue3.Occlusaltrauma.Mobilityalsoincreasesafterperiodontalsurgeryandinpregnancy.Inperiodontalpathologytissuedestructionisalwaysaccompaniedbyinflammationandfrequentlybyocclusaltrauma.Mobility,whichisproducedbyinflammationandocclusaltrauma,isreversible,asdemonstratedbythereductioninmobilityfollowingscalingandocclusaladjustment;mobilityassociatedwithdestructionofsupportingtissueisnotreversible.Assessmentofmobilityforresearchpurposescanbemadeusingspecialapparatusbutclinicalassessmentisusuallysubjective.Itiselicitedbyexertingpressureononesideofthetoothunderexaminationwithaninstrumentorfingertipwhileplacingafingeroftheotherhandontheothersideofthetoothanditsneighbourwhichisusedasafixedpointsothatrelativemovementcanbediscerned.Anotherwayofelicitingmobility(althoughnotassessingit)istoplacefingersoverthefacialsurfacesoftheteethwhilethepatientgrindstheteeth.Thedegreeofmobilitymaybegradedasfollows:Gradel.JustdiscernibleGrade2.EasilydiscernibleanduptolmmlabiolingualdisplacementGrade3.Overlmmlabiolingualdisplacement,mobilityofthetoothupanddowninanaxialdirection.ToothmigrationMovementofatooth(orteeth)outofitsoriginalpositioninthearchisacommonfeatureofperiodontaldiseaseandonewhichalertsthepatienttotheproblem.Abalanceoftongue,lipandocclusalforcesmaintainstoothpositioninhealth.Oncesupportingtissueislosttheseforcesdeterminethepatternoftoothmigration.Theincisorsmovemostfrequentlyinalabialdirectionbutteethmaymoveinanydirectionorbecomeextruded.Onceatoothmigratestheforceonthattoothchangesandthismaypromotefurtherstressandfurthermigration.Ifanupperincisormigrateslabiallythelowerlipmaycometolielingualtotheincisaledgeofthetoothandproducefurthermigration.DiscomfortOneofthemostimportantfeaturesofchronicperiodontitisisthealmosttotalabsenceofdiscomfortorpainunlessacuteinflammationsupervenes.Thisisoneofthemaindistinctionsbetweenperiodontalandpulpdisease.Discomfortorpainonpercussionofthetoothindicatessomeactiveinflammationofthesupportingtissues,whichisatitsmostacuteinabscessformationwhenthetoothbecomesexquisitelysensitivetotouch.Sensitivitytohotandcoldissometimespresentwhenthereisgingivalrecessionandrootexposure.Indeedonecommonclinicalexperienceistheappearanceofsensitivity,especiallytocold,whenrootsoncecoveredincalculusarecleaned.Onoccasionpulppathologymaybeacomplicationofadvancedperiodontaldiseaseandseverepainmaythendevelop.AlveolarbonelossResorptionofalveolarboneandtheassociateddestructionofperiodontalligamentarethemostimportantfeatureofchronicperiodontitis,andtheone,whichleadstotoothloss.Thereisconsiderablevariationinboththeformandrateofalveolarboneresorptionandinconstructingatreatmentplantheamountofboneloss,therateatwhichresorptionisprogressingandthepatternofbonelossneedtobeaccuratelyestablished.Radiographicexaminationisanessentialpartofperiodontaldiagnosisandwithcertainlimitationsprovidesevidenceofthealveolarboneheight,theformofbonedestruction,thewidthoftheperiodontalligamentspaceandthedensityofcancelloustrabeculation.Serialradiographstakenoveraperiodoftimecanprovideinformationabouttherateofboneloss.However,radiographicexaminationwithoutcarefulclinicalexaminationcanbeverymisleading.Aperiodontaldiagnosiscannotbemadefromradiographsaloneasthereisnowayofdistinguishingontheradiographpastbonedestructionfromcurrentboneresorption.Becausetheimagesofthefacialandlingualplatesofbonearelargelyobscuredbythedenseimageofthetooth,diagnosisdependsuponobtainingaclearimageoftheinterdentalbone.CarefulangulationoftheX-raybeamandastandardizedroutineofexposureandprocessingtheradiographicfilmisessential.Thefirstradiographicsignofperiodontaldestructionislossofdensityofthealveolarmargin.Thisismostclearlyseenbetweenposteriorteethwhereinhealththebroadinterdentalseptumprojectsadenseandwell-definedimageofthealveolarmargin.Theimageofthenarrowinterdentalseptabetweenanteriorteethislesswelldefinedinhealthandearlypathologicalchangesarelesseasytosee.Withcontinuingboneresorptiontheheightofthealveolarboneisfurtherreduced.Evencorrectlyangulatedtheradiographsmaynotdisclosethetruestateofinterdentalresorption,e.G.Aninterdentalcraterbetweenmolarscanbemaskedbytheimagesofthefacialandlingualwallsofthedefect.Bonedefects,whichlieoverthefacialorlingualaspectsoftheteeth,e.G.Marginalgutters,maybecompletelyobscuredandrevealedonlywhenflapsareraisedatsurgery.Moreover,distinguishingbetweenfacialandlingualdefectsmaynotbepossiblefromradiographicevidencealone.Tworadiographstakenatslightlydifferentanglesoftenrevealdefectsundetectedbyone.Thisisespeciallytrueinthediagnosisoffurcationdefects.Theseareusuallyrevealedbyradiographicexaminationbuttheexactformofthedefectmaynotbediscernible.Thethickpalatalrootofanuppermolarmaymaskatrifurcationdefect.Wideningoftheperiodontalspaceinthefurcationprovidesevidenceofanearlylesion.Wideningoftheperiodontalspaceononesideorallaroundatoothfrequentlyindicatesexcessiveocclusalstress.Thisissometimesaccompaniedbywideningorfunnellingofthecoronalaspectofthesocket.Alldeparturesfromthenormalradiographicappearancemustbecheckedagainstotherclinicalfeatures,inparticularpocketdepthandmobilitypatterns,andifthesedonotcorrespondreexaminationshouldbecarriedout.Clinicalfeaturestakentogethershouldmakeareasonablefit,whichshedslightonboththepathologicalconditionanditsaetiology.Thus,whereradiographicexaminationofamobiletoothrevealsthatthesupportingboneisvirtuallyintact,carefulexaminationoftheocclusionisessential.Theremustalwaysbeanidentifiablereasonforanypathologicalchange.HalitosisandoffensivetasteAnoffensivetasteandsmellfrequentlyaccompanyperiodontaldiseaseespeciallywhenoralhygieneispoor.Acuteinflammation,withtheproductionofpus,whichexudesfrompocketsonpressure,alsocauseshalitosis.Asourceofconstantsurpriseisthelackofawarenessofaffectedindividualsandtheirspousestothepowerfulfetor,whichlikeamalignantwindescapesfromtheirmouthswhentheyspeak.Lackofsensibilityandunconcernaboutdentalhealthseemtogohandinhand,andaspatientcooperationisessentialtothesuccessofperiodontaltreatmentthissensibility,orlackofit,canprovideacluetoprognosis.Diagnosis,prognosisandtreatmentplanMakingadiagnosisThediagnosisshouldnotbelimitedtogivinganametothecondition.Ifperiodontaldiseaseistobetreatedanditsrecurrenceprevented,adiagnosisshouldincludetheidentificationofallaetiologicalfactors,i.e.(i)thosefactorswhichpredisposetoplaquedepositionandretention,and(ii)thosefactors,localorsystemic,whichinfluenceadverselythebehaviorofthetissue.Itshouldgowithoutsayingthatyoucannotremoveorcontrolfactors,whichhavenotbeenidentified,yetalltoofrequentlytreatmentisreducedtothecontrolofsignsandsymptoms,andinevitablydiseaserecurs.Atthetimeoftheinitialexaminationsomeattemptshouldbemadetoassessthepatient’sattitudetodentalhealth.Patientcooperationisessentialtothesuccessofperiodontaltreatmentanditisthisfactwhichmakesthetreatmentofperiodontaldiseasedifferentfromthatofcariesandotherdentaldiseaseswhenthepatientcantakeamorepassiveattitude.PatientexaminationTheexaminationshouldbemethodicalandcomprehensiveandshouldfollowthestandardpatternoftheclassiccasehistory.PresentcomplaintanditshistoryApatientwithperiodontaldiseasemayhavenocomplaintatallandtheobvioustothepresenceofanydiseaseinthemouth;indeed,thepatientmaybesuspiciousofanysuggestionthatdiseaseispresent!Themostcommoncomplaintsarebleedinggums,looseteeth,driftingoftheteeth(usuallytheupperincisors),nastytaste,halitosis,swellingofthegums,discomfortandoccasionallyacutepain.Fewpatientsattheinitialconsulationprovideconciseandcompletelyrelevantinformation.Alltoooften,thenecessaryinformationhastobeelicitedbyabstractionfromalong,sometimesrambling,andaccountwhichmustbelistenedtowithpatienceandcloseattention.Inaddition,Pertinentquestionsshouldbeasked:Areyouinpain?Whereisthepain?Isitathrobbingordullpain?Doesthepainkeepyouawake?Whatbringsonthepain--hot,cold,sweet,biting?Haveyouhadpaininthepastoristhisthefirsttime?Whattreatmenthaveyoureceivedforpain?Doyourgumseverbleed?Whenyoubrushyourteeth?Whenyoueathardfood?Didyourgumsbleedinthepast?Whattreatmentdidyoureceive?Doanyofyourteethfeelloose?Haveyoualwayshadthatspacebetweenyourfrontteeth?Haveyouhadanyswellinginyourmouth?Where,when,etc.?DentalhistoryDoyougotothedentistregularly?Whatwasthelasttreatmentyoureceived?Whendidyoulasthaveascaling,i.e.Cleaningbyyourdentist?Doyouhaveanydentures(falseteeththatyoucantakeout)--howlonghaveyouhadthem?Haveyouanyfalseteeththatarefixedin--howlonghaveyouhadthem?Atthisstagequestioningabouthomecarecanbeawasteoftime.Answerstosuchquestionsas‘Howoftendoyoucleanyourteeth?”areoftensuspect,asthepatientislikelytosaywhatheimaginesheissupposedtosay,i.e.twiceaday,nightandmorning.Evenifthishappenstobethetruth,itgivesnoindicationofthequalityoftheperformance;onlyanexaminationofthemouthprovidesinformationaboutthat.Atthistime,someideaabouthabitsshouldbegleaned,e.g.smoking,clenching,andnightgrinding,andbitingpencilsandsoon.MedicalhistoryAlthoughamedicalhistorymaynotseemrelevanttosomepatients,itisessentialtoobtainoneforanumberofreasons:l.Thepatientmaybesufferingfromsomecondition,e.g.Cardiovasculardisease,renaldisease,etc.,whichwinrequirespecialprecautionsand/ormodificationofthetreatmentandwillnecessitatecommunicationwiththepatient’sphysician.2.Systemicconditions,e.g.Pregnancy,diabetes,winalterthewayinwhichtheperiodontaltissuesbehaveandmaydemandmedicalattentionbeforeperiodontaltreatmentcanbecarriedout.3.Themouthmaybethesiteofsomemanifestationofasystemiccondition,e.g.Anaemia,whichcouldaffectanyperiodontaltreatment.4.Thepatientmaybereceivingmedication,e.G.Monoamineoxidaseinhibitorsfordepression,whichmayconnectwithmedicationinvolvedintheperiodontaltreatment,e.g.Generalanaesthetics.Amedicalhistoryshouldrecordanypresentillnessandmedication;anypastseriousillnessandmedication,e.g.Steroidstakenintherecentpast,allergies,especiallyanyhistoryofpenicillinsensitivity,abnormalbleedingtendencies,inparticularexcessivebleedingafterinjuryortoothextraction.Theuseofaquestionnairemaybehelpful.Wheresomesystemicproblemexists,communicationwiththepatient’sphysicianisessential.PatientappraisalWhiletakingthehistory,ageneralappraisalofthepatientshouldbemade,andsuchfeaturesasobesity,generalposture,pallor,skinrash,heavybreathing,lippostureshouldbenoted.OralexaminationTheexaminationofthemouthshouldbecarriedoutinamethodicalandthoroughmanner;thisisthedentist’sspecialarea.Halitosisisnoted,asthemouthisopenedorevenearlierwhenthepatientisgivingahistory.l.Theoralmucosa,cheeks,lips,tongue,palate,floorof’mouthandvestibules,areexaminedforulceration,vesicles,swelling,erodedpatches,abnormalcolourandwhitelinesorpatches.Toothindentationsinthemarginofthetongueandinterdentalkeratosis,i.e.Awhitelineinthecheekattheleveloftheocclusion,oftenindicatesaclenchingorgrindinghabit.Aphthousulcersfrequentlyoccurinthelabialorlingualvestibuleorinsidethelips.Lichenplanusmaybeseenasfine,interlacingwhitelinesonthecheeksoralveolarmucosa.Vesiclesorerodedpatchesshouldbefullyinvestigated.Asinusonthealveolarmucosawithorwithoutthedischargeofpusonpressure,indicatesthepresenceofanalveolarabscess.Intheolderindividual,asquamous-cellcarcinomamayappearasapainlessswelling,ulcerorerodedwhitepatchinanypartoftheoralmucosa,butespeciallyinthevestibules.Orallesionsofprimary,secondaryortertiarysyphilismayappearonthelips,tongue,palateandeventhegingivae;widespreadcandidalesionsinayoungmalecouldbeindicativeofHIVinfection.Anydeparturefromthenormmustbeexaminedcarefully,andifinfectionormalignantdiseaseissuspected,anexaminationofthesubmandibularandcervicallymphnodeswillhelpwithadiagnosis.Immediatereferraltothephysicianorappropriatespecialistisessential.2.Removableappliances,ifpresent,shouldbeexaminedfortheirfit,designandrelationshiptoanyinflammationoftheoralmucosaandgingiva.3.Oralhygiene.Notepresenceandpositionofplaque,supragingivalandsubgingivalcalcalus.SubginigivalcalculuscanbedetectedwithasharpprobeoraCrosscalculusprobebutmayalsobeseenasadarkblueshadowinthegingivalmargin.Theuseofadisclosingagentwillhelptoidentifyplaqueanddemonstrateitspresencetothepatient.Sometimesthelocationofplaqueandcalculuspointstoapredisposingfactor,e.G.Betteroralhygieneontheleftsideisusuallyassociatedwithright-handedtoothbrushing;interproximaldepositsandgingivalinflammationmaybecausedbytheoverhangingmarginsofrestorationsorpoorcontactrelations.4.Teetharechartedandcavities,restorationsandmalalignmentsrecorded.Attritionmayindicateagrindinghabit;abrasionavigorousanddamagingtoothbrushingtechnique.5.Gingivaeareexaminedforcolour,shape,sizeandconsistency,keepinginmindthepictureofhealth,pink,knife-edged,streamlinedandfirm,anydeparturefromwhichcouldindicatepathology.6.Pocketmeasurementshouldbecarriedoutoneachtoothandrecorded.Ideally,truemesial,distal,facialandlingualmeasurementsarerequired,butthisispossibleonlywhereteetharemissing,sothatunimpededaccesstothesesurfacesispossible.Whereproximalteetharepresent,measurementismadeatthelineangles,andonfacialandlingualsurfaces.Takingsixreadingsoneachtoothisidealbutmaybeverytimeconsuming,andifdiagnosisismadeatareasonablyearlystageinperiodontalbreakdown,onlyoneortwomeasurementsmadeatthemesiobuccalandmesiolinguallineanglesmaybesufficient.Wherethereappearstobefurcationinvolvementofmolars,ordriftingofincisors,facialandlingualmeasurementsontheseteethareessential.Apocket-measuringprobemustbefineenoughtoenteranarrowpocket,butmusthaveabluntendsothatthetissueisnotperforated.Thesharp-endedprobeusedforthedetectionofcariesshouldnotbeused.Thepocket-measuringprobemustbeinsertedintothepocket,asnearparalleltotheaxisofthetoothaspossible;ifinsertedobliquely,afalsereadingwillbeobtained.Greatcarehastobetakentomanipulatetheprobesothatthetruedepthofthepocketisrecorded.Delicatehandlingoftheprobemastisemployedtonegotiatesubgingivaldepositswithoutimpactingagainsttherootsurface.Vigorousprobingisnotonlypainfulbutalsolikelytogiveaninaccuratereading;evengentleprobingofinflamedgingivaecanbepainful.Theproblemsofpocketmeasurementcanbedemonstratedbythefactthatpocketmeasurementafterlocalanaesthesiausuallygivesgreaterreadingsthanintheunanaesthetizedtissue.Gutta-perchaorsilverpoints,whichmaybecalibrated,maybeleftinsituduringradiographicexaminationofsuspectedinfrabonypockets.Inadditiontorecordingpocketdepth,itisimportanttoassesstheclinicalattachmentlevel(amelocementaljunction,CEJ).Wherethereisconsiderablegingivalhyperplasiapocketingmaybefairlydeep;say5-7mm,butattachmentlossmaybesmallornil.Wheretherehasbeenconsiderablegingivalrecession,ashallowpocketmaybeassociatedwithconsiderabledestructionoftheperiodontaltissues.Therefore,inordertointerpretpocketmeasurement,onemustalsonote(a)theposition