Stent as an accessory tool in periodontal measurements: An insight.

A better reflection of periodontal destruction can be obtained by the measurement of the clinical attachment level (CAL), i.e., the distance from the probe tip to the level of the cementoenamel junction (CEJ). However, there were several problems in CEJ identification. Due to the time consumption and inherent problems in CEJ identification, CAL measurements without using a stent in surveys or other clinical trials are highly questionable. The use of stent is recommended during clinical trials which will minimize the errors in terms of over and underestimation of CALs. Hence, the stent used for vertical probing (vertical/occlusal stent), horizontal probing (furcation stent), and interdental papilla (IDP) stent for IDP-deficiency measurement is discussed to comprehend its clinical applications.

INTRODUCTION

Periodontal probing is of relevance because it permits the dentist to identify sites with a history of periodontal disease or at risk for periodontal breakdown. However, probing depth measurements do not always reflect the extent of periodontal destruction. Frequently, the gingival tissue is inflamed or it is overgrown in response to drug therapy. In such cases, probing depth is a measure of pseudo pocketing, and the extent of periodontal destruction is (grossly) overestimated. In contrast, in situations of gingival recession or after periodontal surgery, probing depth can substantially underestimate the true extent of periodontal destruction. A better reflection of periodontal destruction can be obtained by the measurement of the clinical attachment level (CAL), i.e., the distance from the probe tip to the level of the cementoenamel junction (CEJ).

However, there were several problems in CEJ identification as reported by Vandana and Haneet. The major problems are difficulty in probing due to subgingival location, lack of distinct demarcation felt during probing, vertical course of CEJ on proximal surface, and the tactile sensitivity of the examiner.[1] Despite problems in CEJ identification, CAL measurements are a part of community periodontal index. Due to its time consumption and inherent problems in CEJ identification, CAL measurements without using a stent in surveys or other clinical trials are highly questionable. It is only recommended during clinical trials, which will minimize the errors in terms of over and underestimation of CALs.

There is clinical situation wherein the gingival margin and interdental papilla (IDP) tip measurements are required pre- and postoperatively after recession treatments. In such situations, a modification of existing stent facilitates eases the measurement recording which is easily reproducible and dependable. A similar situation that existed with furcation measurements was solved by introducing a modified furcation stent by Laxman et al.[2] Few studies using furcation stent have reported the efficacy of the same.[2]

Perioesthetics involving IDP-deficiency treatment is gaining popularity, and the clinical measurements of IDP remain obscure as there is no fixed reference point. Based on this lacunae, a modified stent for measurement is effectively used in a clinical trial.[3]

In this short communication, stent used for vertical probing (vertical/occlusal stent), horizontal probing (furcation stent), and IDP stent for IDP-deficiency measurement are presented in terms of its clinical utility during periodontal measurements.

CLINICAL APPLICATION OF STENT IN PERIODONTICS

Stent is a customized accessory measurement tool which is widely used in recording clinical periodontal parameters to minimize error and over and underestimation of measurements during clinical trials.

The difficulties associated with CEJ identification in CAL measurement have led to provision of a fixed reference point coronal which is easily accessible and visible. The use of customized stent provided an alternative which is referred as fixed reference point, and measurements were referred as relative attachment level.

STENT FOR VERTICAL PROBING ATTACHMENT LEVEL OR VERTICAL CLINICAL ATTACHMENT LEVEL (VERTICAL/OCCLUSAL STENT)

The clinical attachment loss which occurs in vertical direction from CEJ to the base of the bone defect is measured as probing attachment level (PAL-V) or clinical attachment level (CAL-V). It is also referred as occlusal stent because of its location on occlusal surface of the teeth [Figure 1].

Figure 1

Vertical stent used for vertical probing attachment level

Thus, probing location is apparently less variable and more reliable. The stent increases the intra and interexaminer reliability and helps to maintain a dependable fixed reference point for clinical measurements in longitudinal controlled clinical trial of shorter duration studies with small sample size.[45]

FURCATION STENT FOR HORIZONTAL FURCATION PROBING ATTACHMENT LEVEL IN FURCATION INVOLVEMENT (FURCATION STENT)

Horizontal CAL is the terms used for horizontal measurement of furcation involvement using a fixed reference point. A fixed reference point is needed to record more precise and reliable measurements of the horizontal component of furcations, free from detection, stability, and reproducibility errors. To overcome these problems, a custom stent provides a fixed reference point for measurement of the horizontal component of furcation and can be used pre- and post surgically without re-entry [Figure 2].[2]

Figure 2

Furcation stent for horizontal furcation probing attachment level in furcation involvement. (a) Diagrammatic representation of furcation stent; (b) Furcation stent with University of North Carolina 15 probe on patient cast model and on patient

MODIFIED VERTICAL STENT FOR INTERDENTAL PAPILLARY DEFICIENCY MEASUREMENT (STENT)

The stent used for vertical probing was modified for IDP measurement. Till now, the stents have been used for measuring vertical PAL and horizontal PAL. However, in today's scenario, many patients are facing the esthetic problem in variety of ways. The third most important is the loss of IDP deficiency. Several treatment options are available to treat IDP deficiency. However, there is lack of stent related to the clinical measurement of interdental papillae pre- and posttreatment. The author of the present study attempted to modify the vertical probing measuring stent to use it for interdental papillae measurement [Figure 3].

Figure 3

Interdental papilla stent for measuring interdental papillary deficiency

METHOD AND DETAILS OF STENT PREPARATION

Customized occlusal stents can be prepared either from cold/heat cure acrylic or thermoplastic materials. The thermoplastic material which is available in different thickness is adapted onto the cast using heating devices [Figure 4]. The uniform thickness of thermoplastic material (2 mm) provides neat finish and allows multiple sites measurement in a given arch at the same time in a single stent. It provides the considerable advantage of avoiding multiple individual stents in a patient which is easily storable.

Figure 4

Preparation of stent using acrylic and thermoplastic material

So far, no clinical measurements of IDP deficiency before and after the treatment are presented in related studies,[6] and their results were presented by photographic evaluation. The modification of stent facilitated ease to measuring IDP changes clinically. Hence, we recommend its use during IDP treatment measurements. Gupta I and Vandana KL also used stent for measuring gingival margin position (gingival recession) at midbuccal site interdentally before and after treatment.[7]

The preparation, storage of stent, advantages, and limitations of the stent are presented in Tables 1-4, respectively [Figures 5-7].

Table 1

Preparation of stent

Table 4

Limitations of stent

Figure 5

Extension of stent margin

Figure 7

Storage of stent

Stent preparation with or without interdental grooves; (a and b) depicts probe angulation unable to touch the papillary tip in an unmodified stent (without interdental cuts till the lower border of stent); (c and d) modified stent with trimming of the interdental groove till the incisal edge allow the probe to touch the interdental papilla parallel to the long axis of tooth

To conclude, the use of stent for vertical probing solved many critical issues in CAL measurement and gingival margin position for gingival recession assessment. Based on this, the furcation stent is a good alternative to gingival margin in furcation measurement which is the first of its kind. IDP stent has provided a reliable mode to measure minor shifts in IDP measurement before and after treatment which is also first of its kind. The clinicians have to utilize the availability of these stents regularly to enjoy the reliability and reproducibility of periodontal measurements data recording during clinical trials.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 2

Storage of stent

Table 3

Advantages of stent