Journal of Indian Society of Periodontology
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Year : 2016  |  Volume : 20  |  Issue : 2  |  Page : 161-166  

Clinical and postextraction evaluation of periodontal disease indicators

Department of Periodontics and Implantology, VSPM Dental College and Research Centre, Nagpur, Maharashtra, India

Date of Submission01-Jan-2015
Date of Acceptance16-Oct-2015
Date of Web Publication11-Apr-2016

Correspondence Address:
Dr. Rajashri Kolte
Department of Periodontics, VSPM Dental College and Research Centre, Digdoh Hills, Hingna Road, Nagpur - 440 017, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-124X.175174

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Background: Clinical attachment level is the most frequently used and acceptable parameter in monitoring periodontal status in diseased individual and denotes patterns of periodontal destruction. Awareness of root morphology and the condition of the periodontal tissues is essential for reliable periodontal pocket probing and for effective debridement of root surfaces. Clinically, it is challenging to observe exact nature of complex periodontal attachment loss. The aim of the present study was to evaluate patterns of periodontal destruction based on vertical and horizontal attachment loss. Materials and Methods: A total of 200 extracted teeth were obtained from chronic periodontitis patients. Prior to extraction, clinical measurements were recorded and after extraction, the teeth were stained with crystal violet. Root length, vertical and horizontal attachment loss were measured using digital caliper. Results: There was a significant difference between clinical attachment level and vertical attachment loss for both maxillary and mandibular teeth. Mean vertical attachment loss varied between 5.17 mm and 9.17 mm. Interproximal surfaces exhibited statistically significant vertical attachment loss in both maxillary and mandibular dentition. Results indicated that vertical attachment loss was more severe with teeth belonging to the anterior sextant whereas the horizontal attachment loss was more pronounced with posterior teeth. Conclusion: Both vertical and horizontal attachment loss were observed in all periodontally involved teeth. There was a difference in clinical measurements and actual periodontal status denoted by postextraction staining. These findings have an impact on determining the prognosis and appropriate treatment plan for patients.

Keywords: Clinical attachment level, extracted teeth, periodontal ligament, root length

How to cite this article:
Kolte R, Kolte A, Wattamwar P. Clinical and postextraction evaluation of periodontal disease indicators. J Indian Soc Periodontol 2016;20:161-6

How to cite this URL:
Kolte R, Kolte A, Wattamwar P. Clinical and postextraction evaluation of periodontal disease indicators. J Indian Soc Periodontol [serial online] 2016 [cited 2021 Apr 11];20:161-6. Available from:

   Introduction Top

Chronic periodontitis is one of the most common inflammatory conditions affecting the periodontal tissues. It is characterized by gradual destruction of the alveolar bone and soft tissues attached to the tooth. Clinically, this destruction is identified and determined by detailed periodontal examination including probing pocket depth, clinical attachment level, and gingival recession. Measurements of the above findings have profound and realistic effects on the prognosis of a particular case and thus help in formulating an adequate treatment plan. Clinical attachment level is the most frequently used and acceptable parameter in monitoring periodontal status in diseased individual in longitudinal studies. Reproducibility of clinical measurements is affected by several factors such as periodontal pocket depth,[1] tooth type (anterior versus posterior),[2] location of measured site (buccal versus lingual or palatal),[3] probing force, and inflammatory status within the periodontal structures. It is felt that a detailed knowledge and awareness of the tooth and root morphology is a prerequisite for a reliable periodontal examination, so as to minimize the variations which are likely to occur in measurements.

The clinical measurements have often been used worldwide to assess the prevalence and severity of the periodontal disease. The data generated are usually presented in terms of mean values for individuals or subsets of groups within the study. The findings thus recorded and calculated are interpreted to show that there is an increasing prevalence and severity of periodontal disease and there is close correlation between levels of oral hygiene and severity of periodontal disease.[4],[5] However, it has been observed that such mean values of individual clinical parameters characterizing the disease were inadequate or at times misrepresented the severity of periodontal disease.[6]

In addition, there has been a sustained evolution of debridement tools over the years in scaling and root planning. With improvised instruments that can be utilized for mechanical debridement, it is most likely and reasonable to achieve improved results, especially in cases of mild to moderate chronic periodontitis.[7] A thorough understanding of the root morphology and the anatomy of periodontal destruction appears to be mandatory for effective debridement of root surfaces.

Several studies in literature have examined the distribution of vertical attachment loss in periodontally affected dentitions.[8],[9] Moreover, these findings have been applied to subgingival debridement of root surface deposits. However, there seems to be paucity of studies examining the prevalence of patterns of horizontal periodontal destruction. It will also be reasonable to compare the clinical measurement prior to extraction of teeth with the vertical and horizontal periodontal destruction as assessed by staining after extraction of teeth.

Hence, this study was planned:

  1. To study and evaluate the patterns of periodontal destruction based on vertical and horizontal attachment loss in extracted teeth and
  2. To compare the clinical measurements with the vertical and horizontal periodontal destruction after tooth extraction.

   Materials and Methods Top

The study comprised patients affected with moderate to severe chronic periodontitis attending the Outpatient Department of Department of Periodontics and Implantology at Vidya Shikshan Prasarak Mandal Dental College and Research Centre, Nagpur, India. Among these patients, teeth with poor prognosis which were indicated for extraction were included in present study as shown in [Figure 1]. The clinical measurements including probing pocket depth, clinical attachment level, and gingival recession were recorded for these teeth after which they were extracted under local anesthesia with adrenaline. Among these extracted teeth, 200 teeth which fulfilled the inclusion criteria of having intact cementoenamel junction (CEJ), no evidence of caries and no history of periodontal treatment in last 6 months were included in the study. Extracted teeth with restoration, extraction damage beyond CEJ, fracture of root apices, or absence of periodontal ligament (PDL) were excluded from this study.
Figure 1: Clinical photograph of tooth before extraction

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The study was approved by the Institutional Ethics Committee. Informed consent was obtained from each patient after explaining the procedure and rationale for extraction of the teeth.

A total 200 maxillary and mandibular teeth (incisors, canines, premolars, and molars) were subjected to staining procedures described by Waerhaug [10] using crystal violet solution. The teeth were immersed in the dye at room temperature for 5 min, then after washing in running water for 10–15 min, they were air-dried. Plaque and calculus were removed after staining to expose the CEJ to facilitate assessment.

Measurement of root length (from most coronal level of CEJ to the root apex) was done using a digital caliper on all the surfaces as it varies according to the location of CEJ [Figure 2]. Similarly, the vertical attachment level measurement on all surfaces was recorded from the most coronal level of the stained periodontal membrane on the long axis of the root to the most apical point of the root [Figure 3]. The difference between the root length and the vertical attachment level was recorded as vertical linear loss of attachment. Six to eight linear measurements were recorded per tooth. Linear loss of attachment was based on the mean of two measurements. The ratio of attachment loss to root length was divided into 4 categories: 0–25, 25–50, 50–75, and 75–100 percentile. Mean vertical loss of attachment was calculated for each root surface and differences were analyzed [Figure 4]. Schematic illustration of horizontal attachment loss is shown in [Figure 5].
Figure 2: Measurement of root length using digital caliper

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Figure 3: Measurement of vertical attachment level

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Figure 4: Measurement of horizontal attachment loss

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Figure 5: Schematic illustration of measurement of horizontal attachment lossFigure

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Horizontal attachment loss was recorded by measuring the distance between the two parallel lines drawn to the most convex (highest) points at the coronal side of the stained periodontal membrane.

Statistical analysis

Statistical analysis was performed using Statistical software STATA version 13.0 (StataCorp. 2013. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP.). Root length, vertical attachment loss and horizontal attachment loss, probing pocket depth, and clinical attachment loss for all maxillary and mandibular teeth were calculated as mean standard deviation. Vertical attachment loss was compared across different surfaces in each type of tooth by performing one-way ANOVA. Post-hoc comparison was carried out by Bonferroni t-test. Mean vertical attachment loss and clinical attachment loss were compared for each surface by performing paired t-test. P < 0.05 was considered as statistically significant.

   Results Top

The details of maxillary and mandibular teeth types, their means of root length, vertical attachment loss, horizontal attachment loss, and the ratio of vertical attachment loss to root length are depicted in [Table 1]. The root length for maxillary teeth varied between 12.00 mm and 17.20 mm for the third molar and canines, respectively. Those for mandibular teeth were seen to be between 12.55 mm and 15.79 mm for central incisor and canine, respectively. The maxillary and mandibular canine being the teeth with maximum root length were also associated with severe vertical attachment loss, whereas this was not the case with the horizontal attachment loss. The ratio of vertical attachment loss to root length as shown in [Table 1] indicates it to be within the second and third categories, i.e., 25–50 and 50–75 percentile.
Table 1: Mean root length, VAL, and horizontal attachment loss for each tooth type

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[Table 2] and [Table 3] depict the vertical and horizontal attachment loss associated with each of the tooth type and on all the four surfaces. Mesial surfaces exhibited most significant vertical attachment loss in maxillary canine, molars followed by mandibular canine, incisors, and second molar (P < 0.05). Mesial surfaces of maxillary first molars exhibited most severe horizontal attachment loss than any other tooth surface. Interproximal surfaces exhibited more attachment loss as compared to buccal/palatal surfaces for all teeth except for maxillary and mandibular molars (P < 0.05, Bonferroni t-test).
Table 2: Mean VAL by type of teeth and surface

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Table 3: Mean horizontal attachment loss by type of teeth and surface

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[Table 4] indicates the comparison of clinical measurements, i.e., clinical attachment levels with the vertical attachment loss both in maxillary and mandibular teeth. It is evident that the clinical measurements appear to be more almost on all the tooth surfaces when compared with the area of absence of periodontal membrane.
Table 4: Comparison of mean VAL and CAL of maxillary and mandibular teeth by surface (by using paired t-test)

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[Table 5] shows the distribution of vertical attachment loss in maxillary and mandibular teeth. It is evident that the percentile is always greater for mesial and distal surfaces for both maxillary and mandibular dentition as compared to the buccal and palatal surfaces and the difference is statistically significant.
Table 5: Distribution of VAL in maxillary teeth and mandibular teeth

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   Discussion Top

The present investigation was conducted on 200 periodontally involved teeth which were indicated for extraction and hence could provide the dual information about the clinical measurements as well as a detailed three dimensional picture at the bottom of periodontal pocket when examined through staining after extraction. There have been reports in the literature examining the vertical attachment loss in extracted teeth, with a few of them commenting even on the horizontal attachment loss. However, all these studies [8],[11] have analyzed the attachment levels in extracted teeth, with no indication or knowledge about the clinical condition of the tooth prior to extraction. The present clinical trial has taken into consideration the periodontal status of the concerned tooth, which thus has enabled in comparing the clinical condition with the vertical and horizontal attachment levels.

An in-depth evaluation of the vertical and horizontal attachment loss and that too in a three dimensional aspect can only and precisely be obtained by measurements from extracted teeth or from histologic sections. These measurements are proposed to be more accurate than the clinical measurements. This approach in measurements is also superior to clinical studies using techniques such as probing pocket depth and radiographs, as all the aspects involving all the surfaces of the tooth can be examined.[12] However, the only limitation of this approach lies in the fact that the tooth has to be extracted for such an evaluation.

There is a definite difference between the clinical and postextraction measurements. However, since in this study, the teeth were periodontally compromised and indicated for extraction, there is all the likelihood that the measurements would have been erred on a higher side. However, even in cases where the teeth are periodontally involved and can be treated, the assessment of horizontal attachment loss cannot be determined. Hence, there could be situations, which possibly might have more amount of periodontal destruction, especially horizontal attachment loss, which may not be detected clinically and may affect the treatment decision and also the prognosis. Though such situation may not be routinely occurring, then such possibility cannot be ruled out.

In the present study, we observed that the clinical attachment levels in the concerned teeth were always greater than the vertical attachment levels measured after extraction and staining. This can be attributed to the fact that the periodontal probe is thought to penetrate the connective tissue at the base of the pocket because the inflammatory condition. These findings are similar to the ones reported by Saglie et al.,[13] Powell, and Garnick.[14] In our study, the difference between clinical attachment level and vertical attachment loss ranged from 0.77 mm to 1.56 mm. These variations in the two findings can be due to the fact that there could have been differences in the inflammatory status of the underlying connective tissue. If these observations are generalized, then the severity of periodontal disease reported in all clinical trials need to be considered critically. Reasonably, accurate measurements could be yielded with pressure sensitive probe.

In our study, since all the teeth were affected with periodontal disease, all the teeth showed presence of vertical as well as horizontal attachment loss. However, there are many instances wherein the presence of periodontal pockets may not be present circumferentially or at the most may be present on one or two surfaces.[15] This means, that the presence of horizontal attachment loss would not be detected in routine detailed periodontal examination. The horizontal attachment loss observed by Yamamoto et al.[11] was in 22.6% of the teeth examined which was far less as compared to our study. In our study, percentage of teeth exhibiting horizontal attachment loss was almost 100%. The difference in percentage could be due to the condition of teeth extracted. In our study, the teeth were included in the trial only when they were periodontally involved and indicated for extraction, while the condition of extracted teeth was not known to the authors in the trial conducted by Yamamoto et al.[11]

Yamamato et al.[16] devised a formula to estimate the remaining root surface area attached to the PDL using computer-aided membrane technique. However, this method seems to be cumbersome one involving multiple steps as also sophisticated equipment and lacks practicability. The technique used in our trial is simple one and can be used as a routine method. It has an added advantage, wherein the clinical measurements can be correlated with the postextraction ones.

Haas et al.[17] employed topographic and histological techniques to assess remaining PDL in a convenience sample of avulsed and intruded human permanent incisors and extracted premolars. However, histological evaluation of transverse root sections of avulsed and severely intruded incisors suggest that the location of PDL tearing during trauma is different from extraction and is characterized by multiple denuded areas where cementum and dentin are exposed.

The results of our study indicate that there is a specific relationship between single and multi-rooted teeth when it comes to the vertical and horizontal attachment loss. It has been observed that in single rooted teeth the vertical attachment loss was more pronounced when compared to the multi-rooted teeth, while horizontal attachment loss was less as compared to the multi-rooted teeth. This could be reasoned out to the more width of the periodontal tissues in multi-rooted teeth or the posterior teeth. For a single rooted teeth, since the width of periodontal tissues is less, whatever loss occurs, manifests itself as the vertical attachment loss, with a few situations, wherein the horizontal attachment loss may also be discernible. These findings are similar to those reported by Halazonetis et al.[3] This observation have clinical implication in terms of prognosis as well as treatment decisions.

The vertical attachment loss in maxillary teeth on mesial and distal surfaces was 9.87–16.79 mm and 9.19–13.81mm, respectively, with maximum in the 75–100 percentiles, while in mandibular teeth it was 9.59–15.3 mm and 9.34–13.5 mm again maximum in 75–100 percentiles, respectively, for mesial and distal surfaces. These findings also replicated for horizontal attachment loss which was seen to be more on mesial and distal surfaces for both maxillary and mandibular teeth. The findings of the present study indicate that the vertical attachment loss as well as horizontal attachment loss on the interproximal surfaces is more as compared to the buccal and lingual surfaces. However, because of the current clinical constraints, the clinician is not in apposition to identify the severity of periodontal destruction on such surfaces. These findings give credence to the understanding that initiation and progression of periodontal disease is more pronounced on proximal surfaces as compared to buccal and lingual/palatal surfaces.

   Conclusion Top

Periodontally affected teeth have been shown to exhibit vertical as well as horizontal attachment loss or combination thereof. However, there could be many conditions, in which component of horizontal attachment loss may not be detected on clinical examination. In addition, there is always a difference in clinical measurements and the actual periodontal status which can be gauged by histologic or postextraction staining methods. These observations do have a bearing on the prognosis and advocating a proper and precise treatment plan for the patients.

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Conflicts of interest

There are no conflicts of interest.

Note: † WORKZONE’ Digital Caliper 6 inch/150 mm LCD display, Shandong, China

   References Top

Deas DE, Pasquali LA, Yuan CH, Kornman KS. The relationship between probing attachment loss and computerized radiographic analysis in monitoring progression of periodontitis. J Periodontol 1991;62:135-41.  Back to cited text no. 1
Goodson JM, Tanner AC, Haffajee AD, Sornberger GC, Socransky SS. Patterns of progression and regression of advanced destructive periodontal disease. J Clin Periodontol 1982;19:472-81.  Back to cited text no. 2
Halazonetis TD, Haffajee AD, Socransky SS. Relationship of clinical parameters to attachment loss in subjects with destructive periodontal diseases. J Clin Periodontol 1989;16:563-8.  Back to cited text no. 3
Scherp HW. Current concepts in periodontal disease research: Epidemiological contributions. J Am Dent Assoc 1964;68:667-75.  Back to cited text no. 4
Ainamo J. Epidemiology of periodontal disease. In: Lindhe J, editor. Textbook of Clinical Periodontology. Copenhagen, Denmark: Munksgaard; 1983.  Back to cited text no. 5
Baelum V, Fejerskov O, Karring T. Oral hygiene, gingivitis and periodontal breakdown in adult Tanzanians. J Periodontal Res 1986;21:221-32.  Back to cited text no. 6
Greenstein G. Nonsurgical periodontal therapy in 2000: A literature review. J Am Dent Assoc 2000;131:1580-92.  Back to cited text no. 7
Anerud KE, Robertson PB, Löe H, Anerud LA, Boysen HM, Patters MR. Periodontal disease in three young adult populations. J Periodontal Res 1983;18:655-68.  Back to cited text no. 8
Yoneyama T, Okamoto H, Lindhe J, Socransky SS, Haffajee AD. Probing depth, attachment loss and gingival recession. Findings from a clinical examination in Ushiku, Japan. J Clin Periodontol 1988;15:581-91.  Back to cited text no. 9
Waerhaug J. A method for evaluation of periodontal problems on extracted teeth. J Clin Periodontol 1975;2:160-8.  Back to cited text no. 10
Yamamoto T, Ishikawa A, Watanabe Y, Hirano N, Shibata Y, Watanabe T. Prevalence of horizontal attachment loss in extracted teeth. J Clin Periodontol 2004;31:791-5.  Back to cited text no. 11
Waerhaug J. Healing of the dento-epithelial junction following subgingival plaque control. II: As observed on extracted teeth. J Periodontol 1978;49:119-34.  Back to cited text no. 12
Saglie R, Johansen JR, Fltra L. The zone of completely and partially destructed periodontal fibres in pathological pockets. J Clin Periodontol 1975;2:198-202.  Back to cited text no. 13
Powell B, Garnick JJ. The use of extracted teeth to evaluate clinical measurements of periodontal disease. J Periodontol 1978;49:621-4.  Back to cited text no. 14
Carranza FA, Camargo PM. The periodontal pocket. In: Newman MG, Takei HH, Carranza FA, editors. Carranza's Clinical Periodontology. 9th ed. Philadelphia: W. B. Saunders Co.; 2002. p. 336-53.  Back to cited text no. 15
Yamamoto T, Kinoshita Y, Tsuneishi M, Takizawa H, Umemura O, Watanabe T. Estimation of the remaining periodontal ligament from attachment-level measurements. J Clin Periodontol 2006;33:221-5.  Back to cited text no. 16
Haas M, Kenny DJ, Casas MJ, Barrett EJ. Characterization of root surface periodontal ligament following avulsion, severe intrusion or extraction: Preliminary observations. Dent Traumatol 2008;24:404-9.  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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