Clinical Attachment Loss

Question 1

Clinical Attachment Loss

Answer 1

The measurement from the CEJ to the base of the pocket

Aids in the diagnosis of periodontal disease

Question 2

Pathogenesis of CAL

Answer 2

Attachment loss begins as an inflammatory change in the connective tissue wall of the gingival sulcus. The fluid inflammatory tissue exudates cause degeneration of the surrounding connective tissue, including gingival fibres.

Question 3

Probing Depth

Answer 3

Periodontal probe Inserted in sulcus/pocket
Parallel to the long axis of the tooth
Do not apply force
Moved apically
Circumferentially around each surface of the tooth

Question 4

Determining CAL

Answer 4

• Assessed in 6 different aspects
  (distofacial, facial, mesiofacial, distolingual, lingual and mesiolingual)
• Once the probing depth (PD) is determined, CAL is calculated as PD + gingival margin to CEJ measurement. Conversely, if the gingival margin is located 2 mm coronal to CEJ, and 5 mm PD is present, the CAL is 3 mm (-2 +5).
• In some cases, the gingival margin is located at the CEJ, in which case the PD and CAL are same.

Question 4

Significance of CAL

Answer 4

1. Provides information relating to the loss or gain of connective tissue attachment
2. The severity of attachment loss is generally, but not always, correlated with the pocket depth. This is because the CAL depends on the location of the base of the pocket from the CEJ, whereas PD is the distance from the gingival margin to the base of the pocket; and the position of gingival margin is variable.
3. Thus teeth with same pocket depth may be associated with different degrees of attachment loss, and pockets of different depths may be associated with same amount of attachment loss.
4. They are extremely useful in clinically monitoring attachment level changes on a site-by-site basis from one visit to the next.
5. CAL measurements are the primary basis upon which a clinician can be reasonably certain that a program of supportive periodontal therapy is working or not.

Question 5

Limitations of attachment level measurements

Answer 5

1. Although attachment level is used as an indicator of the amount of periodontal support at a specific location on the tooth, this measurement does not provide an accurate assessment of support in terms of 3-dimensions or root surface area.
2. CAL represents the evidence of past periodontal disease, and does not provide real markers of future or ongoing attachment loss.
3. The apical extent of periodontal probe penetration and depth measurement has been shown in many studies to be dependent on degree of inflammation, probing force, probe tip design (shape, thickness and diameter), angulation and position of probing, and root anatomy, particularly in furcation areas; and training of the operator.
4. Other factors that are likely to influence clinical measurement of attachment level include intra- and interexaminer reliability, training of the operator, patient discomfort, accuracy of probe markings, and anatomical variations in tooth contours or position.
5. Measurement error may not be homogenous among tooth surfaces, probing depths or patients.
6. Errors in transcription which may occur while manually recording data may also result in accuracies

Question 6

Risk Indicators For Future Attachment Loss:

Answer 6

1. Age –With increasing age the % of subjects showing severe mean AL increased.
2. Systemic diseases –Diabetes and angina appear as the only systemic diseases correlated with AL. Allergy and anemia were negatively correlated with AL.
3. Smoking – There is a trend for increasing severity of AL with increasing packyears.
4. Microbial flora – Grossi et al (1994) found B. forsythus and P. gingivalis are the only two microorganisms showing increasing percentage of positive subjects from healthy to severe AL group.
5. Occupational hazards – The occupational hazards assessed included chemicals, asbestos, radiation. They found that mean AL was significantly greater for the individuals exposed to chemicals and asbestos compared to non-exposed.
6. Gender – Machtei et al (1992)20 found that males exh8. Baseline mean probing depth – increased probing depth increases the risk for future AL
7. Baseline mean recession - increased recession increases the risk for future AL
8. Baseline bleeding on probing – an increased incidence of BOP at baseline is associated with AL.
9. Number of missing teeth - As the no. of teeth decreased, the risk for future AL increased.
10. Tooth variable – Mandibular and maxillary molars and maxillary premolars were the teeth that displayed the highest incidence of clinical AL. maxillary anterior teeth and mandibular premolars demonstrated the lowest incidence of clinical AL.
11. Site variable – Sites with baseline probing depth of ≥8mm demonstrated a significantly greater AL rate compared to sites with 4-7 mm existing pocket depth, which in turn had a significantly greater AL compared to sites with baseline probing depth of ≤3mm.
12. Subgingival temperature – Subjects with high mean subgingival temperature and widespread periodontal destruction appeared to be at greatest risk for new AL. Unchanging sites exhibited lower mean subgingival temp
    ibited higher mean CAL values than females for all measured parameters.
13. Baseline mean attachment level - The presence of existing periodontal disease is a significant risk factor for future AL. The clinical entity of “established periodontitis” is suggested based on the presence of CAL ≥ 6 mm in two or more teeth & one or more sites with PPD ≥ 5 mm23