1. Nichole Dicke, LDH, BS

2.  Remember the dental hygiene process of care?
The ADHA standards of clinical dental hygiene
practice include2:
Assessment – collection, analysis, and
documentation of a patient’s oral and overall
health status and needs.
Evaluation – ongoing review and
documentation of the outcomes of dental
hygiene care

3.  The AAP has stated that a comprehensive
periodontal examination includes periodontal
probe measurements:1
 Probing depth (PD)
 Location of gingival margin (GM)
 Clinical attachment levels/loss (CAL)
 Mucogingival relationships (to identify deficiencies
of keratinized tissues)

4.  The AAP also provides us with the guidelines for
classifying our patients’ periodontal status.
 1 to 2 mm CAL = Slight
 3 to 4 mm CAL = Moderate
 5 to 6 mm CAL = Severe.
Note bleeding and other soft tissue considerations are
NOT included here. The classification is based on
CAL only. Therefore, you may have a patient with
moderate or even severe CAL from previous
periodontitis who is currently “healthy”.

5.  Note!!!! Clinical Attachment LOSS and Clinical
Attachment LEVEL are synonyms. They are
two phrases used as titles for the exact same
thing.
 Example: CAL of 2 means:
Clinical attachment LEVEL is 2mm below the CEJ.
**OR**
Clinical attachment LOSS is 2mm.
Both statements mean the patient has had 2mm of their periodontal
attachment destroyed. The terms are used interchangeably and are
treated the same way.

6.  Periodontitis is diagnosed when a there is
progression of attachment loss, requiring
documentation of increased CAL between at
LEAST two time points. 1
 Evaluating CAL is critical for deciphering
between active periodontitis and gingivitis on a
reduced but stable periodontium. 1
 Measuring PD alone can result in unnoticed
progression of CAL.

7.  Common CPC approach:
1. Measure all probing depths
2. Measure visible recession and enter this into the
“GM” section of the chart.
3. Print out the graphics from Dentrix to use as
visual of the patient’s CAL as calculated by the
software program.
4. If no recession was present, subtract the “normal”
sulcus depth (such as 3mm) from probing depths
to estimate CAL and use this for classifying the
patient’s periodontal status.

8. The term recession is often used to describe the apical
migration of the gingival margin. When the margin has
migrated far enough for cementum to be exposed, this is
called “visible recession” and is measured by the distance
between the CEJ and the GM.
We need to re-focus on the migration of the
ATTACHMENT towards the apex, rather than the
migration of the GM. After all, the GM only recedes
because the attachment is receding, right?
Which should we be more concerned about: the location
of the gumline, or the amount of periodontal attachment ?

9. FOOD FOR THOUGHT…
CAL = visible recession plus
hidden recession (PD), as
seen in this diagram.
What if all of the recession
(attachment loss) is hidden
because there the recession
has not advanced that far yet?
How do you know how
Nield-Gehrig, J. (2004). much attachment has been
lost?

10.  The problems with the common CPC (we will discuss
each of these in detail):
1. GM is NOT the same as recession.
2. Dentrix perio charts are not set up to be used this
way.
3. CAL is not always being measured accurately.
4. CAL is not determined soon enough!
5. Cannot determine amount of attachment gain
achieved by NSPT.
6. Mucogingival relationships are not being evaluated,
thus not identifying deficiencies in attached gingiva.

11.  Does gingival recession only exist after it has
migrated PAST the CEJ (visible recession)?
 Has recession occurred if a gingival margin that
used to be 3mm coronal to the CEJ is now only
1mm coronal to it?
HIDDEN RECESSION – how to we catch
receding attachment before the CEJ is visible? This is
where it gets a little hairy….try to stay with me!

12. • GM is the position of the free gingival margin
in relation to the CEJ (above OR below),
measured in millimeters.
• If the GM is apical to the CEJ, the measurement
is recorded in millimeters.
• If the GM is located right at the CEJ, the GM
value is zero!
• If the GM is coronal to the CEJ, the
measurement can be recorded as a negative
(think of it as “negative recession”).

13.  Example:
GM = 1 GM = -3 GM = 0

14.  Dentrix assumes we measure GM the “correct”
way, not equating GM with recession. Any box
left blank will be treated as a zero, as if the GM
margin is located right at the CEJ. The CAL is
then automatically calculated as the PD+0.
 But does a PD of 3 mean a CAL of 3?
 The graphic charts will also be
inaccurate, showing CAL in areas where there
is no attachment loss.

15.  Two ways to “fix” this problem:
 1. Tell Dentrix to stop automatically calculating the
CAL. The hygienist will need to manually enter the
CAL values for areas where GM is measured.
 2. Measure GM the “correct” way, which is a very
tedious, time consuming, and often difficult task.

16.  Hygienists are equating GM with recession,
therefore making their CAL calculations
inaccurate.
 Just because there is no visible GM recession
does not mean there is no attachment loss!
Example:
No recession, PD = 3.
No CAL?

17.  In areas with no recession, we cannot assume the CAL
by subtracting the “normal” sulcus depth of 3mm
from the PD measurement. Why not? Several factors
may influence the sulcus depth3, including:
 Blunted papilla
 Inflammation
 Malpositioning
 Gingival overgrowth
 Individual differences
Therefore, not all PD greater than 3 indicates CAL3, just as
PD less than 3 does not always indicate health.

18.  If determining progressive attachment loss is
the key to diagnosing, treating, and
maintaining periodontitis, why are we not
taking great care to measure CAL precisely?
 How can we classify as slight, moderate, or
severe periodontitis without accurately
measuring the criteria used for such
classification?

19.  True or False: If there is no visible
recession, there is no attachment loss.
 True or False: You cannot identify CAL until
recession has occurred.
BOTH ARE FALSE!

20.  What if: Tooth #30 facial PD is 3 with no visible
recession. Would you assume there is no attachment
loss? Probably. But…
One year ago, PD = 3 Today, PD still = 3.
No recession. No CAL detected. Recession 1mm. CAL 4mm.
We need to detect attachment loss BEFORE it progresses this far!

21.  Tooth 30 has a facial PD of 3 and 1mm of
recession. CAL is calculated as 4mm.
WHY WAS THE ATTACHMENT LOSS NOT
DISCOVERED UNTIL IT WAS MODERATE,
OR NEARLY SEVERE?
At this point, there may be minimal attached
gingiva left….but we will discuss this later.

22.  Example: Betty received NSPT on tooth #3,
which originally had a PD of 8mm with no
recession. The post-op PD is 3mm. How much
attachment was gained?
If you did not measure the GM both before and
after, you cannot assume that all 5mm
reduction is due to attachment gain rather than
reduction in inflammation.

23.  Areas with deficient attached gingiva may be
at higher risk for recession, damage from
mechanical forces, or chronic inflammation. 4
 Patients with deficient attached gingiva may
need referred to a periodontist for evaluation.

24.  This section of the Dentrix perio chart is not
often , may hygienists do not know how to:
 Identify the mucogingival junction (MGJ)
 Measure the MGJ width
 Subtract the PD from the MGJ to determine AG.

25.  True or False: There is always attached gingiva if the recession has not
extended past the MGJ.
 FALSE! If the PD is deeper than the MGJ width, there is no longer any
attached gingiva on that surface. This is why it is critical to measure the
MGJ width and subtract the PD depth from it in any areas with CAL.
Example:

26.  WHAT? Inadequate/inaccurate CAL and MGJ
assessments
 SO WHAT? We are not assessing the patients’
periodontal attachments.
 NOW WHAT? Rethink how you assess your
patients! What are you really measuring?
What should you be measuring?

27.  Measure GM as distance from the CEJ to the
gingival margin, either coronal or apical.
 If this is not done, the Dentrix software must be
told to STOP automatic CAL calculation.

28.  How to measure GM coronal to the CEJ:
 Using the periodontal probe, feel for the CEJ. If it is
hard to feel, increase the angle of the probe beyond 10
° (no longer keeping it parallel to the long axis).
 Once the tip of the probe is located at the CEJ, use the
probe markings to determine the distance between the
CEJ and the GM with the probe held between 0º and
10° to the tooth.
 Consistency is the key to detecting changes!!!

29.  The GM measurements must be taken at the
same site as the PD measurements! Why???
A distal GM measurement must be measured
where the distal PD measurement was taken.
You are going to combine the PD with the GM
to assess the CAL for that surface, therefore
these numbers must come from the same
location! Do not measure three areas on a
Buccal surface and then enter them as
DB,B,and MB readings.

30.  Common error: Hygienist takes all three (D, B, and M)
measurements along different points of the BUCCAL surface.
Tooth #30 (Buccal side)
D B M
PD 6 2 5
GM 1 2 3
CAL 7 4 8
Is the CAL accurate for all three surfaces? Is there
really 8mm of CAL on the mesial of this tooth???

31.  Measure the mucogingival width. Identify the MGJ by
one of three methods:5
1. Look for the visible line where mucosa and attached
gingiva meet
2. Use the side of the probe, held horizontally against
the mucosa, and use short vertical movements to detect
where the moveable mucosa turns into fixed gingiva.
3. For facial areas, pull the lip/cheek taught until you
can see where the loose, stretchy mucosa merges with
the attached gingiva.

32. Nield-Gehrig, J. (2004).

33.  Measure the distance from the MGJ to the GM.
To calculate how much of this measurement is
indeed “attached”, subtract the PD from the
MGJ5. Example:

34.  True or False: You need to calculate AG by
subtracting PD from MJG for all buccal/facial
and lingual surfaces of all teeth.
 False. Why?
 The palatal tissue is completely attached. There is no
MGJ. Trick Question? Maybe….but I have seen
hygienists chart MGJ measurements for the
maxillary linguals!

35. This style of periodontal charting is:
 Time consuming!
 More difficult to do.
 Not performed in most private practice offices
in this area.

36. However, Consider:
 What is our goal as dental hygienists? What are
the ADHA standards for clinical practice? What
are the AAP standards for periodontal evaluation?
 Some offices actually DO perform periodontal
assessments this way….and many more may begin
to do so.
 Our main concern in periodontics is attachment,
therefore, attachment should be the focus of
patient assessment.

37.  Could there be a compromise? Turning off the
automatic calculation on the software will remove
the “false CAL” on the charts. Manually
calculating the correct CAL where visible recession
is present would be a minimal effort.
 While measuring GM above the CEJ may not be
realistic for some offices, hygienists should at
LEAST note “zero” GM, which is easy to detect
and would allow us to detect CAL sooner.

38.  American Academy of Periodontology. (2000). Parameter on
comprehensive periodontal examination. Journal of Periodontology , 71,
847-848.
 American Dental Hygienists' Association. (2008). Standards of clinical
dentla hygiene practice. Retrieved October 6, 2010, from
http://www.adha.org/ downloads/adha_standards08.pdf
 Amir, S., Eaton, K.A., Moles, D.R., Needleman, I. (2009). A systemic
review of definitions of periodontitis and methods that have been
used to identify this disease. Journal of Periodontology, 36, 458-467.
 Camargo, P. M., Melnick, P. R., & Kenney, E. B. (2001). The use of free
gingival grafts for aestheticpurposes. Periodontology 2000 , 27, 72-96.
 Nield-Gehrig, J. (2004). Fundamentals of Periodontal Instrumentation and
Advanced Root Instrumentation. Baltimore: Lippincott Williams &
Wilkins.