Attachment Level Measurements Research Articles

Subjective criteria and probing attachment loss to evaluate the effects of plaque control and root debridement

Abstract 11 adult patients with moderate to advanced periodontitis were treated with oral hygiene instruction and an initial, single episode of root debridement. Before therapy, 3 independent clinicians examined all patients and identified sites that in their opinion probably would not respond to the therapy and would continue to lose attachment. On 2 occasions, 3 and 12 months later, the clinicians reexamined and reevaluated all patients and all sites. The results of therapy were also monitored by probing attachment level measurements performed every 3rd month. All 11 patients completed 24 months of follow-up, and 6 subjects were available until 36 months. Sites with probing attachment loss after 12, 24 and 36 months were identified using linear regression analysis and compared to the clinicians' prediction of probing attachment loss. The results demonstrated a limited agreement between probing attachment loss determined by linear regression and the clinicians' predictions of probing attachment loss. It appears that the traditional clinical signs and factors used to forecast and identify periodontal disease activity are only moderately associated with probing attachment loss. This suggests that attachment loss may be caused by several factors, at least following initial therapy. The progression of an inflammatory disease of microbial etiology may be only 1 of such causes. Further studies are needed to clarify the nature and cause of probing attachment loss.

Subjective criteria and probing attachment loss to evaluate the effects of plaque control and root debridement

Abstract 11 adult patients with moderate to advanced periodontitis were treated with oral hygiene instruction and an initial, single episode of root debridement. Before therapy, 3 independent clinicians examined all patients and identified sites that in their opinion probably would not respond to the therapy and would continue to lose attachment. On 2 occasions, 3 and 12 months later, the clinicians reexamined and reevaluated all patients and all sites. The results of therapy were also monitored by probing attachment level measurements performed every 3rd month. All 11 patients completed 24 months of follow-up, and 6 subjects were available until 36 months. Sites with probing attachment loss after 12, 24 and 36 months were identified using linear regression analysis and compared to the clinicians' prediction of probing attachment loss. The results demonstrated a limited agreement between probing attachment loss determined by linear regression and the clinicians' predictions of probing attachment loss. It appears that the traditional clinical signs and factors used to forecast and identify periodontal disease activity are only moderately associated with probing attachment loss. This suggests that attachment loss may be caused by several factors, at least following initial therapy. The progression of an inflammatory disease of microbial etiology may be only 1 of such causes. Further studies are needed to clarify the nature and cause of probing attachment loss.

Quantification of periodontal attachment at multi-rooted teeth.

The purpose of the present study was to estimate the lost attachment surface area (LAS) and the remaining attachment surface area (RAS) of molars from a combination of clinical and radiographic measurements. Clinical and radiographic measurements on 32 maxillary and 26 mandibular molars were correlated with the post-extraction measurements of LAS and RAS. The results indicate that linear models may increase the precision of the estimate of LAS by a factor of 1.2 for maxillary molars and 1.4 for mandibular molars when compared to estimates of LAS using only attachment level measurements. A diagnostic model for RAS predicts the square root of the remaining attachment surface area with the information obtained from the remaining radiographic attachment area and a gingivitis index. It is concluded that modeling of periodontal data may provide a method for predicting lost and remaining periodontal attachment area of molar teeth.

Risk Assessment for Oral Diseases: Reaction Paper

The "gold standard" outcome measure for periodontal diseases is clinical loss of attachment measured with a periodontal probe. All risk factors for periodontal diseases must be estimated against this standard, which provides post hoc evidence of past disease activity. Measurement of clinical attachment level is crude; therefore, rather large changes must be recorded for specificity to be ensured. This apparently results in rather poor sensitivity, masking good predictors that could prove valuable on a population, individual, and site basis. If risk assessment for periodontal diseases is to advance, this problem must be solved.

Reproducibility of attachment level measurements with two models of the Florida Probe®

Clinical assessment of the progression of periodontitis is based on the measurement of periodontal probing attachment levels over time. In calculating these changes, duplicate measurements from fixed reference points, including cemento-enamel junctions and acrylic stents, have been used to assist in detecting progressive disease. The Florida Probe has been previously shown to improve the reproducibility of these measurements when used with an acrylic stent. The objective of the present study was to evaluate the reproducibility of 2 models of the Florida Probe, the original stent model and the modified disk model, in measuring attachment level. The disk probe differs from the stent probe in that it uses the occlusal surface of the tooth as a static reference point in calculating changes in attachment level measurements. In 10 subjects, sites were probed 2 x by 2 examiners using both types of probe. Standard deviations and intra- and inter-examiner correlations were calculated. These results demonstrate that the new disk probe yields reproducible measurements similar to the stent probe and is therefore suitable for use in longitudinal clinical studies.

Clinical, microbiological and immunological characteristics of subjects with “refractory” periodontal disease

The aim of the present study was to analyze the relationship between attachment loss and clinical, microbiological, and immunological parameters in a group of 21 human subjects exhibiting poor response to previous periodontal therapy. All had been treated with periodontal surgery, tetracycline, and subsequent maintenance recalls to periodontists who, upon detection of disease progression, referred the subjects to our clinic. In our clinic, each subject received oral hygiene instruction and a thorough subgingival scaling and root planing utilizing as many appointments as necessary. Clinical indices, including gingival index, bleeding on probing, suppuration, plaque index, pocket depth, and duplicate measurements of attachment level from an acrylic stent, were collected at monthly intervals. Probing measurements were performed using the Florida Probe. When significant attachment loss (0.8-1.2 mm) was detected in at least 1 site, a bacterial sample was taken from that site and from a comparably deep, but non-progressing, control site. Microbial samples were enumerated by darkfield microscopy, on selective and non-selective media, and by predominant cultivable technique. Blood samples were also collected to determine antibody levels against potential pathogens. There was no difference in the amount of plaque present in sites gaining or losing attachment, but losing sites exhibited more bleeding and suppuration. 20 of the 21 subjects were tested; of these, 17 exhibited elevated serum antibody against one or more of the following microorganisms: Actinobacillus actinomycetemcomitans, Bacteroides, gingivalis, and Eikenella corrodens. However, few, if any, of the "classical" pathogens were detected in the plaque samples obtained at the time progressive disease was diagnosed. The only exception was Streptococcus intermedius, which occurred in slightly higher numbers in active sites.

A periodontal probe with automated cemento-enamel detection-design and clinical trials

An automated periodontal probe has been developed to measure pocket depth and attachment loss in a single measurement under controlled force conditions. A natural anatomic landmark, the cemento-enamel junction (CEJ), is used as a reference for attachment level measurements. The CEJ is detected automatically by immediate digital postprocessing of simultaneous measurements of probe tip acceleration and displacement during probing. Clinical trials in the beagle dog model for naturally occurring periodontitis have shown that the automated probe, when used with 35 g probing force, has a repeatability of 0.16 mm and a bias of 0.09 mm. These results indicate that the automated periodontal probe is capable of attachment level measurements with a high degree of repeatability and validity.

Cross‐sectional and longitudinal reliability for clinical measurement of attachment loss*

Progression of marginal periodontitis in humans is characterized by acute exacerbations during short periods of time followed by periods of remission. The analytical procedures used to distinguish actively progressing sites from non-progressing sites within an individual's dentition are controversial. The purpose of the present investigation was to use measurements of probing depth and attachment level from a prospective longitudinal study of episodic periodontal disease progression to examine measurement and diagnostic reliability. In 10 systemically healthy adult human subjects with untreated advanced periodontitis, probing depth and attachment levels were measured at baseline and every 30 days for 10 to 12 months. Measurements were made at 6 sites of each tooth using an acrylic onlay as a reference point and a pressure sensitive probe. Replicate measurements were made on sites showing apparent changes in attachment loss of 2 mm or more in a month, and their contralateral counterparts. Cross-sectional reliability was described by means and standard deviations for the absolute differences between replicate measurements: 0.63 +/- 0.87 mm for anterior teeth, 0.58 +/- 0.80 mm for premolars and 0.69 +/- 0.91 mm for molars. The mean differences tended to decrease with increasing time on study and tended to be greater in deeper pockets. Longitudinal reliability was described by analyzing site-specific serial attachment level measurements across the study time period. Maximum likelihood methods were used to estimate false positive and false negative diagnostic rates associated with the diagnosis of attachment loss based on minimum threshold levels of 1 and 2 mm. The use of a 1 mm threshold resulted in estimated false positive rates of 0.08 to 0.11 and false negative rates of 0.11 to 0.15.(ABSTRACT TRUNCATED AT 250 WORDS)

The Relationship Between Probing Attachment Loss and Computerized Radiographic Analysis in Monitoring Progression of Periodontitis

This study attempted to evaluate quantitative changes in radiographic density as an indicator of progression of periodontitis. Twenty-one subjects with a history of periodontitis were monitored at baseline, 3, 6, and 9 months using duplicate probing attachment level (PAL) measurements from stents and computer assisted densitometric image analysis (CADIA) of standardized radiographs. Results indicate that the majority of sites exhibited no PAL change during the 9-month period; however, the percentage of sites with loss increased with time. A mean of 6.1% of the sites/patient exhibited probing attachment loss during the study, as compared to a mean of 38.3% of the sites/patient that exhibited a loss of radiographic density. Due to the two dimensional nature of radiographs, density analysis was calculated in terms of radiographic "complexes" of multiple probing sites. There was significantly more density loss at complexes with greater than or equal to 2 mm of attachment loss than at sites with no change in PAL at 9 months; there was no such difference noted at 3 and 6 months. Also, density loss tended to increase as more sites within each complex experienced PAL. Although there was a significant correlation between mean density and PAL changes during the same time interval, there were wide variations at individual sites. This study suggests that there is a complex relationship between density change on radiographs and PAL change. The difficulties inherent in comparing highly sensitive new technologies to relatively imprecise clinical measurements of the attachment level are discussed.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical risk indicators for periodontal attachment loss

The purpose of the present investigation was to evaluate the association of baseline clinical parameters of periodontal disease with disease progression in the following year. 271 randomly selected subjects from Ushiku Japan were monitored for overt gingivitis and plaque accumulation at 4 sites per tooth and probing pocket depth, probing attachment level and bleeding on probing at 6 sites per tooth for all teeth at baseline and 1 year. A subject was considered to exhibit additional attachment loss if one or more sites increased 3 mm or more in a probing attachment level measurement in one year. The clinical variables included age, sex, number of missing teeth, mean pocket depth and attachment level. In addition, the % of sites which exhibited overt gingivitis, visible plaque, pocket depths, attachment levels or gingival recession over certain mm thresholds or bled on probing were determined. Chi 2 analysis was used to seek significant associations between the baseline clinical variables and subsequent attachment loss in a subject. Only 74 of the 271 subjects (27.3%) exhibited additional attachment loss of 3 mm or more at 1 or more sites after 1 year. Older subjects had a greater risk of disease progression than younger subjects. There were no significant differences in % of individuals exhibiting additional attachment loss when divided on the basis of sex, number of missing teeth or % of sites with overt gingivitis. However, the greater the % of sites with visible plaque or which bled on probing, the greater was the likelihood of subsequent attachment loss. Increasing mean levels of pocket depth or attachment level or increasing %s of sites exhibiting prior attachment loss were strongly related to the proportion of individuals with subsequent attachment loss. Gingival recession exhibited similar but weaker relationships. Log-linear analysis suggested that the association between bleeding on probing, age, or plaque levels with additional attachment loss may be explained by the association of these variables with baseline attachment loss. The analyses were repeated with a positive subject defined as having only 1 active site or 2 or more active sites. 37 subjects fit the 1st criterion and the remaining 37 the 2nd criterion. The associations observed were almost identical to those found when subjects were considered positive on the basis of 1 or more changing sites. Discriminant analysis was used to classify subjects as active or inactive using up to 11 predictor variables.(ABSTRACT TRUNCATED AT 400 WORDS)

Efficacy of Clindamycin Hydrochloride in Refractory Periodontitis: 24‐Month Results

The purpose of this investigation was to evaluate the use of clindamycin hydrochloride in the treatment of adult refractory periodontitis. Thirty patients with a history of unsuccessful treatment with scaling, periodontal surgery, and the use of tetracyclines were entered into the study. Upon entry, the suspected refractory patients were scaled several times and then monitored for the presence of active disease by probing attachment level measurements performed in duplicate. Active disease was defined as a 3.0 mm or greater loss in attachment from the baseline examination or the occurrence of a periodontal abscess. When active disease was detected, patients were treated with scaling and clindamycin 150 mg qid for 7 days. Patients served as their own controls. Twenty four patients demonstrated further attachment loss following scaling alone and were treated with clindamycin hydrochloride. Scaling and clindamycin treatment decreased the incidence of active disease from an annual rate of 8.0% to 0.5% of sites per patient (P less than .001). The mean time required to detect the first active site increased from 4.9 +/- 3.7 months following scaling alone to 16.7 +/- 7.6 months following scaling and clindamycin (P less than 001). Active sites lost an average of 3.1 mm of probing attachment following scaling alone but "gained" back 2.0 mm at 6 months and 1.5 mm at 24 months post-antibiotic and scaling treatment. Bleeding on probing was significantly reduced (P less than .05) from 31.8% of sites pre-clindamycin treatment to 12.3% at 12 months and 17.9% of sites at 24 months post-clindamycin treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Periodontal conditions in a group of Swedish adolescents (I). A descriptive epidemiologic study

The aim of the present study was to describe, clinically and radiographically, the periodontal conditions in 16- and 18-year-old adolescents from Northern Sweden. The studied samples comprised 287 16-year-olds and 283 18-year-olds. The clinical examination included recording of presence of plaque, bleeding on probing and calculus, and measurements of attachment level and pocket depth. Alveolar bone level was measured on bite-wing radiographs. A history was taken of the individual's occupation, oral hygiene habits and tobacco use, health, medication and previous orthodontic treatment. The prevalence of attachment loss (AL) was 9.4% in the 16-year-olds and 19.4% in the 18-year-olds. Proximal AL was found in 2.8% and 4.9%, respectively, and proximal bone loss in 1% in both groups. With only a few exceptions (3 individuals out of 82), the individuals with AL had their loss either at buccal/lingual surfaces or at proximal surfaces. Calculus was present in 32.7% of the 16-year-olds and in 44.9% of the 18-year-olds. Pocket greater than 3 mm were found in 4%. No significant differences concerning the periodontal status or presence of plaque and calculus were detected between urban and rural groups or between sexes. Toothbrushing 2 or more times/day was performed by 84.3% of the 16-year-olds and by 83.7% of the 18-year-olds.

Controlled force measurements of gingival attachment level made with the Toronto automated probe using electronic guidance

Precise reproduction of probe placement, probing force and probing angulation may influence the reliability of replicate gingival attachment level measurements (GAL). Reproducibility of GAL measurements was determined with the Toronto automated periodontal probe (TAPP) in which a novel electronic guidance system was incorporated to improve the precision of probing angulation. Bench testing of forces produced at the probe tip was performed with an electronic balance. Reproducibility and precision of force generation were tested in a variety of instrument configurations using laboratory models. The data indicated that highly precise and reproducible probing forces can be generated with the TAPP over a large (10 to 90 g) probing range. Instrument precision was +/- 0.27 mm when probing forces of 40-60 g were used. The guidance system provided accurate and reproducible measurements of the probe handle in both roll and pitch axes when compared with precisely machined wedges (R = 0.99, roll; R = 0.98, pitch). Deviation of probing angulation greater than 5 degrees on replicate measurements of GAL was associated with significant alterations in the location of circumferential probe placement and in the size of the difference between GAL measurements (delta GAL). Clinical assessment of probing angulation in 6 patients demonstrated that delta GAL was 0.40 +/- 0.05 mm when probing angulation deviation was less than 5 degrees but increased to 0.96 +/- 0.11 mm when deviations exceeded 5 degrees. Taken together, these data indicate that the regulation of probing angulation in clinical measurement of GAL with the TAPP is an important determinant of the reproducibility of periodontal probing.

Subjective criteria and probing attachment loss to evaluate the effects of plaque control and root debridement

11 adult patients with moderate to advanced periodontitis were treated with oral hygiene instruction and an initial, single episode of root debridement. Before therapy, 3 independent clinicians examined all patients and identified sites that in their opinion probably would not respond to the therapy and would continue to lose attachment. On 2 occasions, 3 and 12 months later, the clinicians re-examined and re-evaluated all patients and all sites. The results of therapy were also monitored by probing attachment level measurements performed every 3rd month. All 11 patients completed 24 months of follow-up, and 6 subjects were available until 36 months. Sites with probing attachment loss after 12, 24 and 36 months were identified using linear regression analysis and compared to the clinicians' prediction of probing attachment loss. The results demonstrated a limited agreement between probing attachment loss determined by linear regression and the clinicians' predictions of probing attachment loss. It appears that the traditional clinical signs and factors used to forecast and identify periodontal disease activity are only moderately associated with probing attachment loss. This suggests that attachment loss may be caused by several factors, at least following initial therapy. The progression of an inflammatory disease of microbial etiology may be only 1 of such causes. Further studies are needed to clarify the nature and cause of probing attachment loss.

Comparison of Measurement Variability Using a Standard and Constant Force Periodontal Probe

This study compared the intra- and inter-examiner reliability of the Florida Probe, Florida Disk Probe, and conventional periodontal probe. Using these instruments, each of three examiners made repeated measurements of probing depth (using the Florida Probe and conventional probe), relative attachment level (using the Florida Disk Probe), and clinical attachment level (using a conventional probe) at posterior, proximal sites in 10 subjects with early periodontitis. The mean intra-examiner standard deviation of differences in repeated probing depth measurements ranged from 0.46 to 0.77 mm demonstrating similar levels of reproducibility between the Florida Probe and conventional probe. The mean intra-examiner standard deviation of differences in repeated relative attachment level measurements using the Florida Disk Probe ranged from 0.44 to 0.57 mm using double passes and from 0.98 to 1.41 mm using single passes of measurements. For clinical attachment level measurements obtained using single passes of measurements with a conventional probe, the mean intra-examiner standard deviation of differences ranged from 0.78 to 0.95 mm. Inter-examiner variability was generally greater than intra-examiner variability for all instruments. It was concluded that double passes with the Florida Disk Probe offers significant advantages for measuring relative attachment level in longitudinal studies of early periodontitis when decisions for change must be made as soon as possible.

Class II Furcations Treated by Guided Tissue Regeneration in Humans: Case Reports

In the cases reported here, the response of Class II mandibular molar furcation defects to guided tissue regeneration (GTR) versus sham operation was evaluated. Base-line information, including probing pocket depth (PD) and clinical attachment level (CAL) measurements, was recorded after completion of the hygienic phase. Eleven experimental and six control furcations, randomly assigned, are included in this report. The furcations were surgically exposed, using a flap approach and the areas were debrided. On the experimental teeth, Gore-Tex periodontal material was adapted and sutured, using a suspensory suture. The flaps were then sutured tightly, assuring complete coverage to the material. For 1 month all patients were seen weekly and rinsed their mouths with an 0.12% chlorhexidine solution daily. After 4 to 6 weeks the Gore-Tex membranes were removed. Clinical measurements were repeated at 3 and 6 months following surgery. Changes from baseline in PD and CAL were calculated for each case. Results indicated that PD measurements were reduced by both procedures, but the reduction was better for GTR at 3 and 6 months. At six months the test sites showed 2.8 +/- 1.0 mm pocket reduction, while the control sites showed an average of 1.6 +/- 0.9 mm reduction in pocket depth. CAL recordings were improved by both treatments, but were better for GTR at 6 months, with an average gain in CAL of 1.8 mm for the GTR and 0.6 mm for the controls. These cases in which GTR was compared to sham-operated controls indicate that GTR can improve the response to therapy of Class II furcation defects.

Statistical Properties of Some Clinical Measures of Gingivitis and Periodontitis

Various statistical properties of the plaque index, the gingival index, and the whole-mouth averages of pocket depth and attachment level measurements were examined using data from a 4-year randomized trial of 80 patients with a history of treated periodontal disease. Departures from normality were assessed by the median of the standardized distribution, by the coefficients of skewness and kurtosis, and by the Kolmogorov goodness-of-fit test. The relative precisions of probing pocket depth and of attachment level were measured, as were correlations between repeated measurements over time for the four clinical measures. The distribution of the plaque index was far from normal, but the distribution of its logarithm was more nearly normal. The distributions of the other clinical measures were effectively normal to varying degrees of approximation. With only rare exceptions, correlations between repeated measurements on the same clinical variable remained relatively constant no matter how far apart in time the measurements were made, at least up to 4 years. The whole-mouth mean of the attachment level measurements seemed to be relatively more precise than the whole-mouth mean of the pocket depth measurements.

Evaluation of clinical and radiographic scoring methods before and after initial periodontal therapy

The purpose of the present study was to compare the determination of the attachment level by probing and by measuring bone heights prior to and after the completion of a hygienic phase of periodontal therapy. 68 patients with moderate to severely advanced periodontitis underwent initial (hygiene phase) therapy including scaling and root planing, oral hygiene instructions and the elimination of plaque retention factors. Measurements of pocket probing depths, probing attachment levels and the location of gingival margins in relation to the cemento-enamel junction were performed at 4 aspects of each tooth with a thin calibrated probe at a baseline examination and 3 to 5 months following treatment. During these 3 to 5 months, the patients were kept in a maintenance care program. On the full-mouth radiographs obtained at baseline, the distance from the cement-to-enamel junction to the marginal alveolar crest was measured in millimeters and as a % of the root length. Furthermore, a subgroup of 11 patients, who were scheduled for modified Widman flap procedures, received another full-mouth radiographic examination before the surgical treatment. In addition, the level of the alveolar crest was assessed with a periodontal probe during the surgical procedure. The comparison of the different clinical and radiographic parameters showed the best correlations between the various radiographic measurements of bone heights (r = 0.87; r = 0.86). Clinical measurements of probing attachment level and probing level of the alveolar crest revealed slightly weaker correlations (r = 0.72). When comparing radiographic bone heights with clinical measurements of probing attachment levels, the lowest correlations were found (r = 0.65; r = 0.61; r = 0.61).

Effect of non-surgical periodontal therapy combined with adjunctive antibiotics in subjects with "refractory" periodontal disease. (I). Clinical results.

The aim of the present study was to evaluate the clinical effect of non-surgical periodontal therapy with the adjunct of a selected antibiotic in subjects with refractory periodontitis. 10 subjects were selected for the study; all had a history of periodontal surgery, tetracycline therapy, and regular maintenance by a periodontist. Clinical registrations including gingival index, plaque index, presence of bleeding and suppuration, pocket depth, and duplicate measurements of attachment level were performed at baseline and at monthly intervals. When disease activity was detected based on the tolerance method, a bacterial sample was taken from the active site and its susceptibilities to a number of antibiotics were determined. For the selected 10 subjects, Augmentin was the antibiotic of choice. Each subject received 750 mg/day for 2 weeks, during which time a full-month scaling and root planing was performed under local anesthesia. Clinical re-evaluation was performed after 3, 6, 9 and 12 months. At the time disease activity was detected, the average loss of attachment at all active sites was 2.2 mm, and the increase in pocket depth 1.5 mm. At 3 months post-therapy, these sites had regained 2 mm of attachment which remained stable through the 12-month examination. Pocket depths decreased 2.5 mm over the first 6 months and then stabilized. The frequency of all sites that gained 1 mm or more of attachment increased by approximately 10% over the first 9 months following therapy. The frequency of all sites that decreased 1 mm or more in pocket depth increased approximately 15% over the same period.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantification of periodontal attachment at single-rooted teeth.

The measurement process of attachment loss has been criticized in recent years. Problems with clinical interpretation, precision of the measurement, and statistical manipulation of the obtained data, are some of the problems associated with the present methodology. The purpose of the present study was to propose an alternative measurement process which addresses some of the existing problems by estimating the lost attachment surface area (LAS) and the remaining attachment surface area (RAS) from a combination of clinical measurements. The results show that a linear combination of several sources of clinical information can be used to predict RAS and LAS. A diagnostic model for LAS (R2 = 81.5%) predicts the square root of LAS with information obtained from bucco-lingual attachment level measurements, the radiographic lost attachment area, the gingivitis index and the radiographic tooth length. This model increases the precision of the estimate of LAS by a factor of 1.86 when compared to the estimate of LAS using only attachment level measurements. A diagnostic model for RAS (R2 = 75.5%) predicts the square root of RAS with the information obtained from the remaining radiographic attachment area, the gingivitis index and the mobility index. Both linear inference models are constructed with measurements of anatomical landmarks to avoid the discrepancy between anatomical and clinical measurements in the produced estimates. It is concluded that modeling of periodontal data provides a simple, inexpensive, and precise diagnostic tool for predicting the lost and the remaining periodontal attachment of single-rooted teeth. Measurement processes of this type could provide a convincing basis for the evaluation of clinical decisions and research questions.