This assignment has two sections: direct clinical measurements (Section I) and radiographic
interpretation (Section II). Here's how you can approach each question:
Section I: Clinical Measurements
1. Width of Attached Gingiva
Formula: Calculate the width of the attached gingiva by subtracting the probing
depth from the total width of the gingiva.
Step 1: Measure the total width of the gingiva from the gingival margin to the
mucogingival junction
Step 2: Measure the probing depth (from the gingival margin to the base of the
pocket)
Step 3: Subtract the probing depth from the total width of the gingiva to compute
the width of the attached gingiva.
○ Measure from the gingival margin to the mucogingival junction. Subtract the
probing depth from this measurement.
2. Thickness of Gingiva
○ Use a periodontal probe or ultrasound. Insert the probe perpendicularly to the
gingiva or assess using transillumination.
3. Diagnosis of Abnormal Frenum
○ Examine its attachment and mobility. An abnormal frenum may pull the gingiva
away from the teeth, cause a diastema, or interfere with oral functions.
4. Gingival Recession
a. Step 1: Measure the probing depth (gingival margin to the probe tip).
b. Step 2: Measure the amount of recession (from the CEJ to the gingival margin).
c. Step 3: Calculate the CAL by adding these two measurement together (e.g., 2
mm probing depth + 3 mm of recession - 5 mm CAL).
○ Measure the distance from the cementoenamel junction (CEJ) to the gingival
margin using a periodontal probe.
5. Bleeding on Probing
○ Gently probe the sulcus or pocket around the teeth. Check for bleeding within 10
seconds.
6. Tooth Mobility
○ Use two instrument handles to apply alternating pressure. Classify mobility as
Grade I (slight), Grade II (moderate), or Grade III (severe).
7. Probing Depth
○ Measure the depth of the gingival sulcus using a calibrated periodontal probe.
8. Clinical Attachment Loss (CAL)
○ Add probing depth to the gingival recession if the gingival margin is apical to the
CEJ. Subtract it if the margin is coronal.
9. Alveolar Bone Loss
○ Measure the distance between the CEJ and the alveolar crest on radiographs.
10.Furcation Lesions
○ Use a furcation probe (e.g., Nabers probe) to evaluate horizontal and vertical
involvement.
Section II: Radiographic Interpretation
1-3. Normal Anatomical Landmarks
● Identify structures like the alveolar crest, lamina dura, and periodontal ligament space on
radiographs.
4-5. Bone Loss and Periodontal Disease
● Look for horizontal or vertical bone loss patterns and signs of chronic or aggressive
periodontitis.
6-7. Bone Loss and Periodontal Disease
● Assess the extent and pattern of bone destruction to classify the disease.
8-9. Furcation Involvement
● Classify involvement using radiographs into Grade I (incipient), Grade II (partial), or
Grade III (complete).
10.Defect by Arrows
○ Analyze the defect; it could be a vertical defect or crater depending on the bone
loss shape.
11.Defect Seen in the Radiograph
○ Define it based on the extent and appearance (e.g., furcation defect, three-wall
defect).
Tips for Answering:
1. Handwritten Answers: Write neatly and systematically.
2. Illustrations: Add diagrams for clarity, especially for Section II.
3. Clinical Terms: Use proper terminology for accuracy.
Let me know if you want detailed guidance on specific points or additional help understanding
the assignment!
Let’s break down each section with detailed guidance and explanations so you can confidently
understand and answer each point.
Section I: Clinical Measurements
1. How do you measure the width of attached gingiva?
● What it is: The attached gingiva is the part of the gums tightly bound to the underlying
bone.
● How to measure:
○ Use a periodontal probe to measure the total distance from the gingival margin
(edge of the gum) to the mucogingival junction (where attached gingiva ends and
alveolar mucosa begins).
○ Measure the probing depth (the depth of the sulcus or pocket).
○ Subtract the probing depth from the total measurement to get the width of the
attached gingiva.
○ Example: If the total distance is 6 mm and the probing depth is 2 mm, the width
of the attached gingiva is 6−2=4 mm6 - 2 = 4 \, \text{mm}.
○ The attached gingiva is continuous with the marginal gingiva. It is irm, resilient,
and tightly bound to the underlying periosteum of alveolar bone. The facial aspect
of the attached gingiva extends to the relatively loose and movable alveolar
mucosa; it is demarcated by the mucogingival junction (see Fig. 3.2). The width
of the attached gingiva is another important clinical parameter.7 It is the distance
between the mucogingival junction and the projection on the external surface of
the bottom of the gingival sulcus or the periodontal pocket. It should not be
confused with the width of the keratinized gingiva, although this also includes the
marginal gingiva The width of the attached gingiva on the facial aspect differs in
different areas of the mouth.40 It is generally greatest in the incisor region (i.e.,
3.5 to 4.5 mm in the maxilla, 3.3 to 3.9 mm in the mandible) and narrower in the
posterior segments (i.e., 1.9 mm in the maxillary irst premolars and 1.8 mm in the
mandibular first premolars)6 (Fig. 3.3). Because the mucogingival junction
remains stationary throughout adult life,4 changes in the width of the attached
gingiva are caused by modifications in the position of its coronal portion. The
width of the attached gingiva increases by the age of 4 years and in supraerupted
teeth.5 On the lingual aspect of the mandible, the attached gingiva terminates at
the junction of the lingual alveolar mucosa, which is continuous with the mucous
membrane that lines the floor of the mouth. The palatal surface of the attached
gingiva in the maxilla blends imperceptibly with the equally firm and resilient
palatal mucosa.
2. How do you measure the thickness of gingiva?
● What it is: The thickness refers to how thick the gum tissue is.
● Methods:
○ Transgingival probing: Insert a needle or probe perpendicularly to the gingival
surface until it contacts the bone, then measure the depth.
○ Ultrasound: A non-invasive method that uses sound waves to measure
thickness.
○ Clinical Significance: Thicker gingiva is more resilient to trauma and surgery.
3. How do you diagnose abnormal frenum?
● What it is: The frenum is the tissue connecting the lip or cheek to the gums.
● Signs of abnormality:
○ Pulling the frenum while observing gum movement or gaps between teeth
(diastema).
○ Interference with brushing or speech.
○ Conduct a "blanch test" by pulling the lip and observing tissue whitening around
the frenum.
○ Clinical Implication: Abnormal frenum may cause recession, diastema, or
difficulty in maintaining hygiene.
4. How do you measure gingival recession?
● What it is: Gingival recession is the exposure of tooth roots due to gum margin
displacement.
● Measurement:
○ Place a periodontal probe at the CEJ.
○ Measure the distance from the CEJ to the gingival margin.
○ Clinical Significance: It indicates the severity of gum disease or trauma.
5. How do you check for bleeding on probing?
● What it is: Bleeding indicates inflammation in the gums.
● Procedure:
○ Gently insert the periodontal probe into the gingival sulcus or pocket.
○ Check for bleeding within 10 seconds.
○ Clinical Note: The presence of bleeding suggests gingivitis or active periodontal
disease.
6. How do you measure tooth mobility?
● What it is: Tooth mobility assesses the stability of a tooth.
● Procedure:
1. Use two blunt instruments (e.g., mirror handle and probe).
2. Apply gentle pressure alternately from the facial and lingual sides.
3. Grade the mobility:
■ Grade 0: No mobility.
■ Grade I: Up to 1 mm horizontal movement.
■ Grade II: >1 mm horizontal movement.
■ Grade III: Vertical movement present.
7. How do you measure the probing depth?
● What it is: The distance from the gingival margin to the base of the sulcus/pocket.
● Procedure:
1. Insert a periodontal probe into the gingival sulcus until resistance is felt.
2. Record the measurement at six points per tooth (mesial, middle, distal for both
facial and lingual).
8. How do you measure clinical attachment loss (CAL)?
● What it is: The total loss of attachment between the tooth and surrounding tissues.
● Procedure:
○ Add the probing depth to the gingival recession if the gingival margin is apical to
the CEJ.
○ Subtract the probing depth if the margin is coronal to the CEJ.
○ Clinical Significance: Indicates progression of periodontal disease.
9. How do you measure alveolar bone loss?
● What it is: Bone loss due to periodontal disease.
● Procedure:
1. Examine radiographs to measure the distance between the CEJ and the alveolar
crest.
2. Normal distance: 1-2 mm. Anything greater indicates bone loss.
10. How do you measure furcation lesions?
● What it is: Bone loss in the space where the roots of multi-rooted teeth divide.
● Procedure:
1. Use a furcation probe (e.g., Nabers probe).
2. Check the horizontal depth of involvement:
■ Grade I: Incipient involvement.
■ Grade II: Partial involvement.
■ Grade III: Through-and-through involvement.
Section II: Radiographic Interpretation
1-3. Normal anatomical landmarks
● Common landmarks to identify:
○ Alveolar crest: Appears as a dense line near the CEJ.
○ Lamina dura: A white line surrounding the tooth socket.
○ Periodontal ligament space: A dark line between the lamina dura and root.
4-7. Types of bone loss and periodontal disease
● Bone loss patterns:
○ Horizontal bone loss: Bone height is reduced uniformly.
○ Vertical bone loss: Angular bone defects.
● Periodontal diseases:
○ Chronic periodontitis: Gradual bone loss with plaque buildup.
○ Aggressive periodontitis: Rapid bone loss, often in younger patients.
8-9. Furcation involvement
● Radiographs reveal spaces between roots. Use the same grading criteria (Grade I, II,
III).
10-11. Defects on radiographs
● Defects include craters (concavities in bone), vertical defects, or furcation defects.
Next Steps
● Write your answers systematically and add diagrams where applicable.
● For radiographic questions, study example images of periodontal conditions to recognize
patterns.
● Let me know if you'd like examples, explanations for specific conditions, or help drafting
your handwritten responses.
Section I: Clinical Measurements
1. How do you measure the width of attached gingiva?
Answer: Measure the distance from the gingival margin to the mucogingival junction using a
periodontal probe. Subtract the probing depth from this measurement to get the width of
attached gingiva.
Rationale: The attached gingiva helps protect the underlying periodontal tissues during
mastication. Its width is critical for maintaining periodontal health. (Source: Carranza’s Clinical
Periodontology, 13th Edition)
2. How do you measure the thickness of gingiva?
Answer: Insert a periodontal probe or needle perpendicularly into the gingiva until it contacts
the bone, or use an ultrasound device.
Rationale: Gingival thickness affects wound healing and surgical outcomes. Thicker gingiva
provides better resistance to trauma. (Source: Newman and Carranza’s Clinical Periodontology,
13th Edition)
3. How do you diagnose abnormal frenum?
Answer: Pull the lip or cheek and observe if the frenum causes gingival tissue movement,
recession, or a diastema. Perform a blanch test to check for tension.
Rationale: Abnormal frenal attachments can interfere with oral hygiene, cause diastemas, or
lead to gingival recession. (Source: Carranza’s Clinical Periodontology, 13th Edition)
4. How do you measure gingival recession?
Answer: Measure the distance from the cementoenamel junction (CEJ) to the gingival margin
using a periodontal probe.
Rationale: Gingival recession exposes the root surface, making it susceptible to sensitivity and
caries. Measuring recession helps evaluate the extent of tissue loss. (Source: Lindhe’s Clinical
Periodontology and Implant Dentistry)
5. How do you check for bleeding on probing?
Answer: Gently insert a periodontal probe into the gingival sulcus or pocket and observe for
bleeding within 10 seconds.
Rationale: Bleeding on probing indicates inflammation and is a key sign of gingivitis or active
periodontal disease. (Source: Clinical Periodontology and Implant Dentistry, 6th Edition)
6. How do you measure tooth mobility?
Answer: Apply alternating pressure on the tooth’s facial and lingual surfaces using two blunt
instruments. Grade mobility as:
● Grade I: Up to 1 mm horizontal mobility.
● Grade II: >1 mm horizontal mobility.
● Grade III: Vertical mobility.
Rationale: Tooth mobility reflects the integrity of the periodontal ligament and alveolar
bone. Increased mobility suggests periodontal tissue destruction. (Source: Carranza’s
Clinical Periodontology, 13th Edition)
7. How do you measure the probing depth?
Answer: Insert a periodontal probe into the gingival sulcus until resistance is felt, and measure
the distance from the gingival margin to the base of the sulcus.
Rationale: Probing depth assesses the severity of periodontal pockets and is critical for
diagnosing periodontal disease. (Source: Clinical Periodontology and Implant Dentistry, 6th
Edition)
8. How do you measure clinical attachment loss (CAL)?
Answer: Add the probing depth to the gingival recession when the gingival margin is apical to
the CEJ. Subtract the gingival margin level from the probing depth when the margin is coronal to
the CEJ.
Rationale: CAL reflects the cumulative damage to periodontal support and is essential for
determining disease progression. (Source: Lindhe’s Clinical Periodontology and Implant
Dentistry)
9. How do you measure alveolar bone loss?
Answer: Measure the distance between the CEJ and the alveolar crest on radiographs.
Normally, this distance is 1-2 mm. Any increase suggests bone loss.
Rationale: Radiographic assessment of bone loss helps evaluate the severity and pattern of
periodontal destruction. (Source: Carranza’s Clinical Periodontology, 13th Edition)
10. How do you measure furcation lesions?
Answer: Use a Nabers probe to assess the horizontal and vertical involvement in multi-rooted
teeth. Grade the involvement:
● Grade I: Incipient involvement.
● Grade II: Partial involvement.
● Grade III: Through-and-through involvement.
Rationale: Furcation lesions indicate advanced periodontal disease and require specific
management strategies. (Source: Clinical Periodontology and Implant Dentistry, 6th
Edition)
Section II: Radiographic Interpretation
1-3. Identify the following normal anatomical landmarks:
Answer: The alveolar crest, lamina dura, and periodontal ligament space should be identified.
Rationale: Recognizing normal anatomy on radiographs is crucial for distinguishing
pathological changes. (Source: Radiographic Interpretation for Periodontal Disease, Clinical
Periodontology)
4-5. What type of bone loss can be seen? What type of periodontal disease?
Answer: Analyze the radiograph for horizontal or vertical bone loss. Horizontal bone loss is
typical of chronic periodontitis, while vertical bone loss suggests aggressive periodontitis.
Rationale: The pattern of bone loss provides insight into the type and progression of
periodontal disease. (Source: Lindhe’s Clinical Periodontology and Implant Dentistry)
6-7. What type of bone loss can be seen? What type of periodontal disease?
Answer: Similar to 4-5, identify the bone loss pattern and link it to a periodontal disease type.
Rationale: Accurate diagnosis is key for treatment planning. (Source: Clinical Periodontology
and Implant Dentistry, 6th Edition)
8-9. Classify the furcation involvement seen in the radiographs:
Answer: Use the classification system for furcation involvement (Grades I-III).
Rationale: Furcation assessment aids in determining prognosis and treatment. (Source:
Carranza’s Clinical Periodontology, 13th Edition)
10. What is the defect shown by the arrows?
Answer: Analyze the defect for characteristics of a vertical bone defect or crater.
Rationale: Identifying defects informs surgical planning. (Source: Lindhe’s Clinical
Periodontology and Implant Dentistry)
11. What is the defect seen in this radiograph?
Answer: Classify the defect based on radiographic appearance (e.g., furcation defect,
three-wall defect).
Rationale: Radiographic interpretation ensures accurate diagnosis and management. (Source:
Radiographic Interpretation for Periodontal Disease, Clinical Periodontology)
Attachment loss is the apical migration of the dentogingival junction— the periodontal
attachment apparatus—as a result of the inflammatory response. The dentogingival junction
consists of the epithelial attachment and the connective tissue attachment. The dimension of the
dentogingival junction is called the biologic width and averages 2.04 mm.21 In healthy
conditions, without attachment loss, the connective tissue attachment of the dentogingival
junction begins coronally at the cementoenamel junction, and the epithelial attachment exists
coronal to the connective tissue attachment. With attachment loss, the cementoenamel junction
becomes exposed. Clinical attachment loss measures the amount of attachment loss that has
occurred, with the cementoenamel junction as the reference point. Clinical attachment loss is
measured as the distance from the cementoenamel junction to the bottom of the probeable
crevice. When the gingival margin is located on the anatomic crown, clinical attachment loss is
determined by subtracting the distance from the gingival margin to the cementoenamel junction
from the probing depth. If both are the same, clinical attachment loss is zero. When the gingival
margin coincides with the cementoenamel junction, clinical attachment loss is equal to probing
depth. When the gingival margin is located apical to the cementoenamel junction, clinical
attachment loss is greater than probing depth. Therefore clinical attachment loss, or the
distance between the cementoenamel junction and the bottom of the probeable crevice, is the
sum of gingival recession and probing depth. Drawing the gingival margin on the chart where
probing depths are entered helps to clarify this important point.70 Clinical attachment loss is
automatically calculated in many dental practice management software programs as the sum of
probing depth and recession. This calculation is accurate only when both probing depth and
recession are entered into the software correctly. However, when recession is not entered, many
software programs assume the cementoenamel junction is at the level of the gingival margin
and equate clinical attachment loss to probing depth. This is not necessarily correct, as many
clinicians do not enter a value for recession when the cementoenamel junction is subgingival
and not visible. As such, automatically calculated clinical attachment loss values must be
scrutinized before they are used to help make a diagnosis. Attachment Level Attachment level
describes the location where the dentogingival junction begins coronally on a tooth. For
example, the attachment level of a tooth can be on the coronal third of the root or the apical
third of the root. Clinical attachment level measures the distance between the attachment level
and a reference point on a tooth, such as the cementoenamel junction. For example, the
attachment level is 3 mm apical to the cementoenamel junction. Changes in the attachment
level can be the result of a gain or a loss of attachment, and they can provide a better indication
of the degree of periodontal destruction or gain. Shallow pockets attached at the level of the
apical third of the root connote more severe destruction than deep pockets attached at the
coronal third of the root (see Chapter 23). LEARNING BOX 32.10 Clinical attachment loss
measures how much attachment loss has occurred using the cementoenamel junction as the
reference point. Clinical attachment level measures the distance between where the periodontal
attachment apparatus begins coronally on a tooth and a fixed reference point. Attached Gingiva
It is important to establish the relationship between the bottom of the pocket and the
mucogingival junction, especially at sites with gingival recession and narrow gingival width (see
Fig. 32.11). The width of the attached gingiva is the distance between the mucogingival junction
and the projection on the external surface of the bottom of the gingival sulcus or the periodontal
pocket. It should not be confused with the width of the gingiva, because the latter also includes
the marginal gingiva (see Fig. 32.17
The width of the attached gingiva is determined by subtracting the sulcus or pocket depth from
the total width of the gingiva (i.e., the gingival margin to the mucogingival line). The amount of
attached gingiva is generally considered to be insuficient when the stretching of the lip or cheek
induces the movement of the free gingival margin. Other methods that are used to determine
the amount of attached gingiva include pushing the adjacent mucosa coronally with a dull
instrument and painting the mucosa with Schiller’s potassium iodide solution, which stains
keratin.
