Documenting the level of attachment helps the clinician determine the amount of periodontal destruction that has occurred and is essential when rendering a diagnosis of periodontitis (loss of connective tissue attachment) 1617 This measurement also provides the clinician with more detailed and accurate information regarding the prognosis of an individual tooth. The clinical attachment level (CAL or AL) is determined by measuring the distance between the apical extent of the probing depth and a fixed reference point on the tooth, most commonly either the apical extent of a restoration and/or the cemen-toenamel junction (CEJ). This measurement can be documented on modified periodontal charts (Fig. 1-18) and incorporated with the standard periodontal documentation (see Fig. 1-17) to complete the clinical periodontal examination. When the free margin of the gingiva is located on the clinical crown and the level of the epithelial attachment is at the CEJ, there is no loss of attachment, and recession is noted as a negative number. When the level of the epithelial attachment is on root structure and the free margin of the gingiva is at the CEJ, the attachment loss equals the probing depth, and the
Fig. I -1 7. Chart for recording pocket depths. The parallel lines are approximately 2 mm apart. Fol lowing are the notations involved in using the chart:
1. Block out any missing teeth
2. Draw a red X through the crown of any tooth that is to be extracted.
3. Record the gingival level with a continuous blue line.
4. Record pocket depths with a red line interrupted at the proximal surfaces of each tooth.
5. Shade the pocket form on each tooth with a red pencil (between the red and blue lines).
6. Indicate bifurcation or tr¡furcation involvements with a small red X at the involved area.
7. Record open contacts with vertical parallel lines (II) through the area,
8. Record improper contacts with a wavy red line (V) through the area.
9. Record gingival overhang(s) with a red spur (a) through the area.
10. Outline cavities and faulty restorations of periodontal significance in red.
11. Indicate rotated teeth by outlining in blue to show their actual position.
(Modified slightly from Goldman IIM, Cohen DW: Periodontal therapy, ed 5, Si Louis, 1973, Mosby.)
recession is 0. In a situation in which there is increased periodontal destruction and recession, the loss of attachment measurement equals the probing depth plus the measurement of recession (see Fig. 1-18, B, C). Clinical attachment loss is a measure of periodontal destruction at a site, rather than current disease activity, and it may be considered the diagnostic "gold standard" for periodontitis.19 It should be documented in the initial periodontal examination.") It is an important consideration in the development of the overall diagnosis, treatment plan, and prognosis of the dentition and can be an effective research tool.
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