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   Table of Contents    
ORIGINAL ARTICLE
Year : 2016  |  Volume : 20  |  Issue : 4  |  Page : 391-395  

The efficacy of transgingival probing in class II buccal furcation defects treated by guided tissue regeneration


1 Department of Periodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Submission11-Jun-2015
Date of Acceptance20-Jul-2016
Date of Web Publication14-Feb-2017

Correspondence Address:
Monika Bansal
Department of Periodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-124X.189222

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   Abstract 

Background: The objectives of the present study were to establish transgingival probing as an evaluating method in the clinical studies of periodontal regenerative techniques and to compare the effectiveness of transgingival probing to the surgical entry. Materials and Methods: Ten systemically healthy persons (20–50 years) with moderate to severe chronic periodontitis participated in this study. These cases were recruited into the study only when they fulfilled the eligibility criteria. Vertical probing depth (VPD) and horizontal probing depth (HPD) of furcation defects were measured with and without opening the flap, following local anesthesia during initial surgery and at 6 months after collagen membrane placement. The defect fill (DF) was also noted. The mean measurements of clinical parameters were compared by two-tailed paired t-test at 5% level of significance. Results: The difference between the measurements of VPD and HPD taken during transgingival probing and after opening the flap was lie in the range of 0.10–0.30 mm at the time of initial surgery and 6 months after surgery that was not statistically significant. Persons experienced slight discomfort or pain during opening the flap as compared to transgingival probing, and this method was also appreciated by the patients as it is easy, simple and does not involve the surgical procedure. Conclusion: The results of the study suggest that measurements recorded during transgingival probing and after opening the flap do not influence the required outcome of regenerative therapies, i.e., DF that was not statistically significant difference from surgical reentry. Therefore, it was concluded that transgingival probing could be used as evaluating parameters to see the outcome of regenerative surgeries and the surgical reentry procedure may be avoided because it is a second surgical procedure, time-consuming and interrupts the healing process.

Keywords: Furcation defects, periodontal regeneration, surgical reentry, transgingival probing


How to cite this article:
Bansal M, Singh TB. The efficacy of transgingival probing in class II buccal furcation defects treated by guided tissue regeneration. J Indian Soc Periodontol 2016;20:391-5

How to cite this URL:
Bansal M, Singh TB. The efficacy of transgingival probing in class II buccal furcation defects treated by guided tissue regeneration. J Indian Soc Periodontol [serial online] 2016 [cited 2017 May 25];20:391-5. Available from: http://www.jisponline.com/text.asp?2016/20/4/391/189222


   Introduction Top


Periodontal disease is one of the most common diseases distributed worldwide which leads to formation of osseous defects of the dentitions. In the field of periodontal regeneration, various membranes have been used in the periodontal osseous defects with the principle of guided tissue regeneration. The outcome of these regenerative methods can be assessed by the four different methods, i.e., histology, probing, radiographs, and direct measurement of bone.[1] Histology determines the extent of new attachment which is the standard method to evaluate these regenerative technologies. Although this method provides the evidence of new attachment, this seems to be unrealistic evaluating method for clinical studies of regenerative techniques due to the associated inherent problems such as biopsy and sacrifice of teeth.[2] Radiographs or direct measurement of bone are the suitable methods in clinical studies to see the bone level. Angulation, brightness and contrast, exposure, processing of radiograph, and ability to interpret the film are the controlling factors in assessment of radiographs that limit the use of radiographs in assessing the periodontal regeneration.[3],[4] Periodontal probing records the pocket depth and clinical attachment level. Depth of probe at the base of pocket was influenced by probing force, inflammation, angulation, probe diameter, and anatomy of tooth. Therefore, periodontal probing is always associated with some error which is greater in furcation area.[5],[6] Direct measurement of the bone includes the surgical reentry and transgingival probing (bone sounding). Surgical reentry is the gold standard method, but it is an invasive, time-consuming procedure and it interrupts the healing process.[2],[7] Transgingival probing is the procedure in which tip of the probe makes direct contact with the bone when the probe is forced under local anesthesia through the gingiva. Greenberg et al. in 1976 have reported that transgingival probing reflects the similar distance as measured after surgical reentry of the alveolar crest at buccal surfaces of the jaw.[8] Ursell compared the alveolar bone level measured through transgingival probing and surgical reentry. He proved that transgingival probing is an accurate method to measure the alveolar bone level (r = 0.975) and was not affected by some local factors such as inflammation, location of the site on the tooth surface, and tooth type.[9] Mealey et al. used the transgingival probing in furcation defects to evaluate the osseous topography and found that it significantly improves the diagnostic accuracy of furcation defects and reduced the percent and degree of underestimation in all furcation types.[10] The present study was designed with the aims to establish transgingival probing as an evaluating method in the clinical studies of periodontal regenerative techniques and to compare the effectiveness of transgingival probing to the surgical entry. The hypotheses were that the efficacy of two study groups, i.e., transgingival probing and surgical reentry, is approximately same.


   Materials and Methods Top


This research protocol was approved by the Institute Ethical Committee. Ten systemically healthy persons between the age of 20 and 50 years with moderate to severe chronic periodontitis participated in this study. The inclusion criteria were class II buccal furcation defects in maxillary and/or mandibular first molars having probing depth >5 mm after phase 1 therapy and no history of systemic disease. The exclusion criteria were unacceptable oral hygiene during the phase 1 therapy, history of allergy, habit of smoking and pan chewing, pregnant or lactating mothers. Written informed consent was obtained from the persons. In the present study, sample size was calculated with the formula:



where P = 0.05, d = 0.10 (absolute error), α = 0.05 at two-tailed test, n = 18 cases.

A total of twenty samples in ten patients were included and equally divided into two study groups.

Phase I therapy

A general assessment of persons was made through their history taking, physical examination, periodontal examination, and routine investigations. Investigations such as orthopantomogram and intraoral periapical radiograph of region of interest were done. All persons received phase I therapy which includes full mouth scaling and root planing manually and by ultrasonic instruments. A minimum of two visits were utilized to complete initial therapy, with oral hygiene education, motivation, reinforcement, and occlusal adjustments done when indicated. Simplified-oral hygiene index was used for assessing the oral hygiene. Approximately 1–3 months following the phase 1 therapy, all persons underwent a reevaluation examination to assess periodontal changes.

Measurements of clinical parameters

Clinical parameters such as vertical probing depth (VPD), horizontal probing depth (HPD) of furcation defects, and defect fill (DF) were evaluated. The periodontal probe was positioned in the midfacial region of the tooth and was inserted into the periodontal pocket parallel to the long axis of the tooth surface. Cementoenamel junction (CEJ) was used as fixed point for measuring the clinical parameters in the present study. Measurements during initial surgery were taken with and without opening the flap, following local anesthesia according to the method used by Mealey et al. 1994[10] with slight modifications in the following manner.

Vertical probing depth of furcation defects

UNC-15 periodontal probe was used to record the vertical depth. The probe was inserted into the periodontal pocket to locate the initial fluting of the furcation, and the measurement from the CEJ to the opening of the furcation (F) was recorded. After that, the probe was progressed further apically up to the alveolar bone, and the distance from the CEJ to the vertical depth of probing (VD) was measured. All measurements were recorded nearest to the millimeter.

VPD of furcation defects = (CEJ-VD) − (CEJ-F).

Horizontal probing depth of furcation defects

A calibrated Nabers probe was used to record the horizontal depth. The probe was inserted into the periodontal pocket to locate the initial fluting of the furcation, and the measurement from the CEJ to opening of the furcation was recorded. After that, the probe was progressed further apically up to the alveolar bone in a horizontal direction, and the distance from the CEJ to the horizontal depth of probing (HD) was measured. All measurements were recorded nearest to the millimeter.

HPD of furcation defects = (CEJ-HD) − (CEJ-F).

Defect fill

The gain of the bone in the vertical and horizontal directions was also measured after 6 months. All measurements were recorded nearest to the millimeter.

DF = (CEJ-VD/HD during initial surgery) − (CEJ-VD/HD after 6 months).

Person perception of discomfort/pain experienced without opening the flap and after opening the flap and person satisfaction regarding treatments was also evaluated.

Surgical protocol

One to 3 months after evaluation of phase 1 therapy, the persons were subjected to surgical procedure. All patients were operated under local anesthesia with a solution of 2% lignocaine with 1:80,000 adrenaline. Anesthesia was administered by either nerve block or local filtration to adequately anesthetize the surgical site. After anesthesia, transgingival probing was done and measurements were recorded before raising the flap [Figure 1] and [Figure 2]. After that, conventional flap with only crevicular incision on the facial and lingual side was reflected. After reflection of the flap, debridement of granulation tissue and root surface deposits were accomplished manually and ultrasonic instrumentation. Inner lining of the pocket was removed carefully. The area was irrigated with sterile saline. After irrigation, the measurements were again recorded [Figure 3] and [Figure 4]. Intramarrow penetration was performed with one-fourth round bur. The defect sites were covered by collagen membrane. Type 1 collagen membrane (Healiguide-Advanced Biotech Product) was used in the study. Flaps were sutured with 3-0 black braided silk suture. The surgical area was covered with a periodontal pack (Coe-Pak).
Figure 1: The vertical depth of furcation defects during transgingival probing

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Figure 2: The horizontal depth of furcation defects during transgingival probing

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Figure 3: The vertical depth of furcation defects after opening the flap

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Figure 4: The horizontal depth of furcation defects after opening the flap

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Postsurgical management

Amoxicillin 500 mg and metronidazole 400 mg three times and diclofenac 50 mg twice in a day were prescribed for 5 days. Persons were asked to use 0.2% chlorhexidine mouthwash twice daily. Routine postsurgical instructions were given and subjects were recalled after 1 week for checkup and removal of sutures and periodontal dressing. Thereafter, postoperative appointments were scheduled at 7th day, 14th day, 1st month, 2nd month, 4th month, and 6th month for evaluation of healing of tissues and oral hygiene. At the 2nd and 4th month visit, a professional prophylaxis was performed.

Sixth-month follow-up

At the 6th month appointment, all furcation sites were again examined at two separate time points as during initial surgery. All measurements were recorded by single examiner in the same manner as previously prescribed.

Statistical analysis

After collecting and editing, data were entered into the MS Excel software and transferred to SPSS 16.0 version (SPSS 16.0 version which is manufactured by IBM Corporation, New York, United States) for analysis. The mean measurements of clinical parameters were compared by two-tailed paired t-test at 5% level of significance.


   Results Top


In the present study, all persons returned at scheduled recall appointments, i.e., 7th day, 14th day, 1st month, 2nd month, 4th month, and 6th month for evaluation of healing of tissues and oral hygiene. The healing was uneventful in all the treated sites. No postoperative complications such as redness, pain, allergy, abscess, or swelling was felt by the persons throughout the study period. During the probing after opening the flap, persons had mild pain or discomfort as compared to transgingival probing which is generally associated with surgical procedure. It was observed that few persons were reluctant to go for second surgery because they found it as an unnecessary procedure. The transgingival probing method was appreciated by the persons it is easy, simple and does not involve the surgical procedure. The time required for measuring the clinical parameters was more in case of surgical sounding. Evaluation of clinical parameters through surgical re-entry to see the outcomes of regenerative surgeries was also somewhat slight costly as the surgical procedure needs surgical items.

The details of the recorded measurements of VPD defects are mentioned in [Table 1]. Mean VPD was 4.00 ± 0.94 mm and 4.20 ± 0.03 mm recorded during transgingival probing and after opening the flap, respectively, at the time of initial surgery. After 6 months, mean VPD was 1.30 ± 0.95 mm and 1.40 ± 1.17 mm measured during transgingival probing and after opening the flap, respectively. At both time points, the difference between the measurements of VPD taken during transgingival probing and after opening the flap was not statistically significant. Mean vertical DF was 3.00 ± 0.82 mm and 2.80 ± 0.79 mm during transgingival probing and after opening the flap. The difference between them was not statistically significant.
Table 1: Vertical probing depth of furcation defects

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The details of the recorded measurements of HD defects are mentioned in [Table 2]. Mean HPD was 4.10 ± 1.10 mm and 4.30 ± 0.48 mm measured during transgingival probing and after opening the flap, respectively, at the time of initial surgery. After 6 months, mean HPD was 2.00 ± 0.67 mm and 1.70 ± 0.48 mm measured during transgingival probing and after opening the flap, respectively. The difference between the measurements of HPD taken during transgingival probing and after opening the flap was not statistically significant during initial surgery as well as after 6 months surgery. Mean horizontal DF was 2.40 ± 0.70 mm and 2.60 ± 0.51 mm during transgingival probing and after opening the flap. The difference between them was not statistically significant.
Table 2: Horizontal probing depth of furcation defects

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   Discussion Top


In the present study, all persons returned at scheduled recall appointments. None of them experienced any postoperative complication, but persons experienced slight discomfort or pain during opening the flap as compared to transgingival probing. The transgingival probing method was also appreciated by the patients as it is easy, simple and does not involve the surgical procedure.

In the present study, the difference between the measurements of VPD and HPD taken during transgingival probing and after opening the flap was lying in the range of 0.10–0.30 mm at the time of initial surgery and at 6 months after surgery that was not statistically significant with each other [Table 1] and [Table 2]. These findings were consistent with the results of the Renvert et al.[11] and Ursell.[9] Renvert et al. reported the mean difference of 0.3 mm, whereas Ursell reported the 0.12 mm between the transgingival probing and surgical bone level. Mealey et al. reported the 0.39 and 0.54 mm mean difference in vertical and horizontal direction, respectively.[10] Mean horizontal DF and vertical DF during transgingival probing and after opening the flap was 2.40 and 2.60 mm and 3.00 and 2.80 mm, respectively. There was a mean difference of 0.20 mm in DF. The results of the present study showed that measurements recorded during transgingival probing and after opening the flap does not influence the required outcome of regenerative therapies, i.e., DF that was also not statistically significant difference from surgical reentry. These results are in accordance with the previous studies in which transgingival probing has also been used in regenerative surgeries and found that bone probing measurements have a high correlation with the surgical reentry measurements and may be a reliable method to evaluate the regenerated bone level in regenerative therapy.[11],[12] In another study in infrabony defects, the bone probing method was compared with the histometric bone level after periodontal regenerative surgeries and found the difference of 0.14 between the bone probing depth and the histometric bone level measurements and coefficient of correlation was 0.90.[13]

Underestimation is much more common in probing depth without anesthesia that is affected by probing force, probe direction, probe tip position, inflammatory condition of the periodontal pocket, particularly in furcation area due to external and internal anatomy of the furcation region and presence of soft tissue over the furcal region.[5],[6],[10] To minimize the underestimation, probing after anesthesia, i.e., transgingival probing, improves the diagnostic accuracy of furcation defects and reduces the percent and degree of underestimation in all furcation types.[10],[14] It has been proved that transgingival probing is a reliable method to measure the alveolar bone level and was not affected by some local factors such as inflammation, location of the site on the tooth surface, and tooth type.[8],[9],[15] Although transgingival probing accurately measures the defect sites, the findings are also mild underestimated due to the presence of factors such as external and internal anatomy of the furcation region and presence of soft tissue over the furcal region. However, these differences are not statistically significant. Therefore, transgingival probing can replace the surgical reentry in regenerative therapies as a clinical diagnostic tool for measuring the DF.

The results of the study might be influenced in positive or negative direction through many variables such as probing force by the examiner, anatomy of the osseous defects, consistency of the bone formed after regenerative therapy, and sample size. To limit the biases related to examiner, all measurements were taken by single examiner. Anatomy of the osseous defects and consistency of the bone formed after regenerative therapy difficult to optimize during transgingival probing in comparison to after opening the flap. Sample size depended on the availability of persons fulfilling the eligibility criteria and 6 months after surgical reentry period.


   Conclusion Top


Within the limitations of the study, the results of the present study suggest that transgingival probing can be used as evaluating parameters to see the outcome of regenerative surgeries and the surgical reentry procedure may be avoided because it is a second surgical procedure, time-consuming and interrupts the healing process.

Acknowledgement

This work was supported by Banaras Hindu University, Varanasi, under XI-Plan research grant.

Financial support and sponsorship

This work was supported by Banaras Hindu University under XI-Plan research grant.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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Caton JG. Overview of clinical trials on periodontal regeneration. Ann Periodontol 1997;2:215-22.  Back to cited text no. 1
    
2.
Reddy MS, Jeffcoat MK. Methods of assessing periodontal regeneration. Periodontol 2000 1999;19:87-103.  Back to cited text no. 2
    
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Patur B, Glickman I. Clinical and roentgenographic evaluation of the post treatment healing of infra bony pocket. J Periodontol 1962;33:164-71.  Back to cited text no. 3
    
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Jeffcoat MK, Wang IC, Reddy MS. Radiographic diagnosis in periodontics. Periodontol 2000 1995;7:54-68.  Back to cited text no. 4
    
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Listgarten MA, Mao R, Robinson PJ. Periodontal probing and the relationship of the probe tip to periodontal tissues. J Periodontol 1976;47:511-3.  Back to cited text no. 5
    
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Moriarty JD, Hutchens LH Jr., Scheitler LE. Histological evaluation of periodontal probe penetration in untreated facial molar furcations. J Clin Periodontol 1989;16:21-6.  Back to cited text no. 6
    
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Caton J, Zander HA. Osseous repair of an infrabony pocket without new attachment of connective tissue. J Clin Periodontol 1976;3:54-8.  Back to cited text no. 7
    
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Greenberg J, Laster L, Listgarten MA. Transgingival probing as a potential estimator of alveolar bone level. J Periodontol 1976;47:514-7.  Back to cited text no. 8
    
9.
Ursell MJ. Relationships between alveolar bone levels measured at surgery, estimated by transgingival probing and clinical attachment level measurements. J Clin Periodontol 1989;16:81-6.  Back to cited text no. 9
    
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Mealey BL, Neubauer MF, Butzin CA, Waldrop TC. Use of furcal bone sounding to improve accuracy of furcation diagnosis. J Periodontol 1994;65:649-57.  Back to cited text no. 10
    
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Renvert S, Badersten A, Nilvéus R, Egelberg J. Healing after treatment of periodontal intraosseous defects. I. Comparative study of clinical methods. J Clin Periodontol 1981;8:387-99.  Back to cited text no. 11
    
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Banodkar AB, Rao J. Evaluating the clinical reliability and accuracy of bone sounding measurement in periodontal defects – A clinical study. J Indian Dent Assoc 2011;5:466-8.  Back to cited text no. 12
    
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Yun JH, Hwang SJ, Kim CS, Cho KS, Chai JK, Kim CK, et al. The correlation between the bone probing, radiographic and histometric measurements of bone level after regenerative surgery. J Periodontal Res 2005;40:453-60.  Back to cited text no. 13
    
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Suh YI, Lundgren T, Sigurdsson T, Riggs M, Crigger M. Probing bone level measurements for determination of the depths of Class II furcation defects. J Periodontol 2002;73:637-42.  Back to cited text no. 14
    
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Kim HY, Yi SW, Choi SH, Kim CK. Bone probing measurement as a reliable evaluation of the bone level in periodontal defects. J Periodontol 2000;71:729-35.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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