Do Patients Feel Gum Measurements, At Hygiene Visits, Are ... · 3 Do Patients Feel Gum Measurements ,At Hygiene Visits Are Helpful For Them? 2011, p.36) Patients may be at a fork

Do Patients Feel Gum Measurements, At Hygiene Visits, Are Helpful For Them?

O’Hehir University Bachelor Of Science In Dental Health Promotion Class #1A-14 July 1, 2014 Key words - Gingivitis, Gum Disease, Oral Health, Periodontal Probe, Periodontitis, Action Research, Dental Hygiene.

Laurie Jo Humphrey Registered Dental Hygienist

1 Do Patients Feel Gum Measurements, At Hygiene Visits, Are Helpful For Them?

----------------------------------------------------ABSTRACT--------------------------------------------------------

Periodontal probe readings/gum measurements are utilized by the dental hygienist to

document health or disease of the periodontium, encourage patients to improve home care

and accept treatment recommendations. The dental hygienist has unique expertise to detect

oral health changes at each hygiene visit giving updated feedback on gum health. In the

absence of discomfort, patients are often unaware of problems in their mouths. Periodontal

probe readings offer a measureable gauge for patients to critique their oral hygiene efforts and

provide proof of necessary treatment.

A random survey was given to 100 patients of a general dentistry practice to determine if gum

measurements at hygiene visits were helpful for them, caused changes in home care choices

and if they wanted to receive this service at future hygiene appointments. Each patient

received an initial periodontal examination. The findings were presented using the periodontal

probe chart and a personal periodontal diagram. These illustrations offer a customized

analysis of the patient’s current gum condition. Full mouth periodontal measurements were

updated at each hygiene visit and compared with previous data.

Ninety-nine percent of survey participants felt gum measurements where helpful for them.

Ninety-three percent felt they made home care changes based on their gum measurements.

One hundred percent of patients wanted to continue receiving gum measurements at future

hygiene visits. Patients come to see the dental hygienist because they have a level of concern

for their oral health. The dental hygienist can elevate the patient’s experience from a cosmetic

cleaning to a science based service improving overall health by offering periodontal probe

readings/gum measurements at every hygiene visit.


DO PATIENTS FEEL GUM MEASUREMENTS, AT HYGIENE VISITS, ARE HELPFUL FOR THEM? -------------------------------------------------INTRODUCTION------------------------------------------------------

Early in my career I realized that periodontal probe readings were a road-map to help me

plan the direction I would guide my patients through a life-long journey to attain and maintain

oral health.

Periodontal probe readings are measurements of the space between the tooth and gum

tissue. This space is called a sulcus or periodontal pocket. Clinical Periodontology asserts,

“The only accurate method of detecting and measuring periodontal pockets is careful

exploration with a periodontal probe.” (Carranza, 2006, p.550) The periodontal probe is a

miniature ruler used to determine the depth of the sulcus/pocket. Healthy sulcus

measurements are 1 to 3 millimeters. When measurements are 4 millimeters or deeper, a

periodontal pocket is present. Periodontitis is an inflammatory infection of the gum and bone

foundation that can lead to tooth loss. This infection often goes undetected by the patient

because gingival inflammation and bone loss are often painless. An American dentist named

John W. Riggs was the first to say, “The probe is a tool to help in the diagnosis of periodontal

disease.” (Carranza, 2002, p.7) Ironically, even though this was said in 1882, this method is

still used today to determine periodontal health status.

One current study indicates that, “over 47% of the United States population has some form of

gum disease.” (Thorton-Evans, 2013) Patients come to a dental hygiene specialist to have a

thorough professional cleaning and to learn about the overall condition of their gums.

Periodontal probe readings/gum measurements provide a quick assessment that can elevate a

patient’s understanding of their current gum health. In Action Research it states, “If patients

wish to create their own future, they have to accept responsibility for the present.” (McNiff,


2011, p.36) Patients may be at a fork in the road that will require a decision about their dental

treatment or a change in home care habits. Once I give the patient information, they can make

their own oral health choices. Change can happen when well-informed patients take

responsibility. Providing gum measurements at every hygiene visit, I have seen patients

embrace oral health behavior change. I think data from this project will confirm my belief that

gum measurements, at hygiene visits, are helpful for patients.

-----------------------------------------------BACKGROUND---------------------------------------------------------

As a child I loved visiting my grandparents. My grandpa was a great story teller and grandma

was a fabulous cook. The problem was, when my grandpa gave me a kiss on the cheek he

always left behind his slobber. The truth was that grandpa had ill-fitting false teeth. My dad

started having gum problems at age 38. His country dentist told him, “You have pyorrhea just

like your dad, so let’s yank your teeth and fit you with dentures.” I have grown up seeing teeth

in a glass. When I was 20 I had swollen, bleeding gums and was diagnosed with gingivitis. I

required several cleanings and a strict home care program. Brushing after every meal and

bedtime, flossing at night and antibacterial rinses got my gums back on track. No dentures for

me!

I started my journey into dentistry by happenstance. Knowing I wanted to be in a profession

where I could care for others, I looked for volunteer opportunities. There was an opening at

the Air Force dental clinic where my family was stationed. Classroom instruction and clinical

experience were provided for dental assistants through this Red Cross program in exchange

for volunteer hours. The dentist I was assigned to had a sister who was a hygienist, this was

the first time I had heard of dental hygiene as a profession. As I began to explore future

employment prospects, some doors closed, but the windows to dental hygiene opened.


When I started dental hygiene school, I was so full of ideas about how I could help my

patients have first rate oral health. Students were taught to begin each hygiene appointment

with periodontal probe readings to educate patients on conditions of gum health or disease

and to substantiate proposed treatment plans. As a dental hygiene graduate I continued probe

readings as a foundation for future practice. Initially patients seemed unfamiliar with the

purpose and benefits of probe readings/gum measurements, but were receptive to the

information. Based on these measurements patients would often accept additional treatment

recommendations immediately and improve their home care. Over time I recognized that even

though some patients did not respond the first or second time they heard their probe readings,

eventually most of them did. Discerning what the measurements mean, some now count on

their fingers to track how many numbers they have that are 4 millimeters and deeper. Others

want a copy of their periodontal probe chart to reference troubled areas requiring home care

improvements. My experience tells me that patients find gum measurements helpful, but I

have to admit, I have never asked them.

----------------------------------------------- METHODOLOGY-----------------------------------------------------

I have a patient who is a mechanic, he does not care about gum measurements and he is,

“not going to change because of the numbers.” That is his choice. However, because of his

profession, he understands the technician needs information to do the best job possible for the

client. I believe patients value my expertise and know that periodontal probe readings are the

data I gather for their gum health assessment. But do patients feel that gum measurements

are helpful for them? Seeking an answer, I devised a four question survey for my patients.

Q1) Do you feel Gum Measurements, at hygiene visits, are helpful for you? If yes, why? If

no, why not?


Q2) Do you change your home care regime because of the Gum Measurements? If yes, how

and why?

Q3) Do you want Gum Measurements at future hygiene visits?

Q4) Are there any other insights you would like to share on this topic?

My employer gave me written permission to distribute the survey to my patients. With the

survey, patients received a permission request and an ethics statement to sign. They were

given a copy and I kept a copy for my records.

My office manager told me our patients had not responded to emails in the past. She

suggested I ask patients to complete the survey before they left the office. So I decided to do

a test. When patients were pre-appointing for their next hygiene visit, front office personnel

would update their email and send out the survey. 18 patients preferred to receive an email

survey. While the majority of patients preferred to stay and complete the survey in office.

Because email surveys were slow to come back, I stopped suggesting that option. If patients

were pressed for time I offered stamped envelopes to return the survey when completed, two

took my stamp. At the close of the survey only five of the emails were returned and neither

stamp came back.

There were also adjustments I had to make with the survey questions.

Q1) Do you feel Gum Measurements, at hygiene visits, are helpful for you? If yes, why? If no,

why not?

Q2) Do you change your homecare because of Gum Measurements? If yes, how and why?

Patients did not respond to the secondary question’s request for additional clarification. I got

more feedback once I highlighted this portion and emphasized its importance. In addition,

many patients found the fourth question confusing. They were just repeating their answers


from questions 1 and 2 and thought, less is best. So I eliminated the question. I regret not

having a question based on treatment selection due to gum measurements.

When I was forming my questions I did a preview with other dental colleagues. Because this

survey is given to patients, I should have included them in a test run. In spite of some

challenges, many patients had a lot to say. The moment I had asked their opinion, I was eager

to examine and understand their input.

Participants

100 patients were given the survey, “Do Patients Feel Gum Measurements, At Hygiene

Visits, Are Helpful For Them?” 60 women and 40 men took part over a 45 day period. The

sampled group was 20 through 83 years of age and had been in the practice 1 day to 23

years.

Chart 1

Age of Patient

# of Patients

20-29 12

30-39 15

40-49 17

50-59 29

60-69 15

70+ 12

Chart 2

Years in Practice

# of Patients

0-4 28

5-9 35

10-14 22

15-19 9

20 + 6


Materials

All patients received a full mouth periodontal examination and charting from the dental

hygienist at their initial prophylaxis appointment including,

*periodontal probe readings/gum measurements *mobility

*gingival recession *bleeding

*total attachment loss *suppuration

*furcation involvement *review of radiographs for bone loss

For the exam I used a Marquis probe because it is slim and has a rounded tip for patient

comfort. This probe style also has black and silver markings at 3, 6, 9, and 12 millimeter

increments that are easy for me to read.

Data was entered into the computer using the Dentrix periodontal examination chart. When

the exam was completed a printout of this chart was reviewed then initialed by the patient and

the hygienist.

New Patient Protocol

The periodontal exam and patient education begins at the same time. Patients are informed

that gum measurements will be called out loud. Numbers 1 to 3 are healthy and numbers 4 or

deeper are unhealthy. This explanation is easy for patients to understand and keeps the exam

moving forward. When the exam is completed the patient is positioned upright to review the

periodontal chart printout and receive a more detailed explanation.

In the past I showed pre-made charts or pictures to explain gum health or periodontal

disease. I remember saying, “Your pockets are better/worse than this picture” or “Your

pockets are between these two pictures”. Patients tried to pinpoint exactly what their gum

health/disease looked like. Patients did not want to take responsibility for a picture of someone


else’s gum problem. So I started drawing pictures on the back of the periodontal chart

printout, the patient’s personal periodontal diagram. Just as no two patients are alike, also no

two diagrams are alike. When I drew my own picture I could customize the drawing to depict

the patient’s pockets, home care recommendations and treatment options.

Personal Periodontal Diagram

Figure 1:

A. This is your molar.

B. This is the triangle of gum tissue that is

between your teeth. (interdental papilla)

C. Healthy gum measurements are 1 to 3

millimeters. (sulcus)

D. The underlying bone supports the tooth

when the gums are healthy.

E. I recommend brushing 2 to 4 times a day

for 2 minutes with a soft toothbrush or

electric brush for plaque/biofilm removal. Figure 1: Healthy Gum Measurements

F. Even when we try our best there is always plaque/biofilm that sifts under the gum.

G. To clean between the teeth and under the gums I suggest you floss one time a day,

toothpick, waterpik or proxabrush. (I draw any home care aid that I feel is suitable for

the patient’s needs.)

Proposed re-care intervals are noted at the bottom of the page.


Figure 2:

Gingivitis

A. This is your molar.

B. This is your red, swollen, bleeding

and slightly tender gum tissue. You

have gingivitis.

C. Unhealthy gum measurements are

4 millimeters (pseudo-pocket) and may

bleed with gentle pressure from the

probe/ruler. Use the patient’s numbers.

D. At this stage the underlying bone is Figure 2: Unhealthy Gum Measurements

still intact and supports the tooth.

E. Plaque and bacteria collect in the space between the tooth and gum causing

inflammation that can be reversed by upgraded home care and timely cleanings.

Periodontitis

E. When plaque and bacteria linger it hardens into a calculus sliver that can infect the gum

and supporting structures.

F. Unhealthy Gum Measurements are 4 to 6 millimeters. (periodontal pocket)

Use the patient’s numbers.

G. Bone loss is now occurring and can be seen on your x-rays.

H. You have periodontitis an infection where plaque, calculus and bacteria further degrade

the gum and bone foundation. If this infection continues to progress, tooth loss is possible.


The personal periodontal diagram is a helpful tool used to explain gum measurements. They

are simple and allow the patient to relax as they absorb the information being shared. There

are limitless variations of pictures and explanations. So I recommend a personal periodontal

diagram that is signed and delivered into every patient’s permanent record.

Probe Every Visit

One of the greatest obstacles for a hygienist is time. As I acquire periodontal probe readings

I often realize there are too many concerns to address in one appointment. For this reason it

is important to probe during every prophylaxis. As the patient returns for future hygiene visits I

can continue to detail and customize their personal periodontal diagram. This brings the

information to the forefront and helps the patient re-learn what they may have forgotten. The

more I perform periodontal probe readings and re-evaluate gum health I can link old

knowledge with new knowledge. This link can equal a greater depth of comprehension about

the patient’s periodontal health status and is an important focus of my action research.

GATHERING and INTERPRETING DATA and GENERATING EVIDENCE

---------------------------------------------------RESULTS-------------------------------------------------------------

A three question survey was designed to determine if patients wanted to continue receiving

gum measurements as a helpful educational tool raising oral health awareness and in

improving their home care.

To avoid bias I did a random study, the first 100 hygiene patients to complete the survey were

included. Patients were given unlimited time and privacy in a consultation room to complete

the questions.


Patient YES Responses # of Patients

Encourage improvement 22

Helps patient focus on bad areas 18

Knowledge/patient education 18

Quantitative data (a gauge of progress or lack thereof) 15

Never explained before (new understanding of gum health) 12

Encourage frequent cleanings 6

Avoid future dental expenses 6

Encouraging, as pockets improve over time 4

Early detection of disease 3

Competition between family members 2

Advanced periodontal patient wishes done sooner to avoid surgery 2

Current feed back 2

Never done before 2

Numbers depict blood pressure, weight and gum health 2

Let me know if I need more root planing 1

Family history of dentures (prevent tooth loss) 1

Patient can hear numbers (auditory learner) 1

Oral disease affects overall health 1

Better oral health indicator than cavities 1

Results oriented 1

Patient NO Responses # of Patients

I don’t care 1


Patient-Responses

Do You Feel Gum Measurements, At Hygiene Visits, Are Helpful For You?

Patient 42 (female, age 33): “Absolutely, learning about gum measurements has taught me

that oral care is a two part maintenance program: tooth care and gum care. I feel that gum

measurements are another important number that we need to know about our body. Most of

us are aware of our weight, cholesterol count, etc. Any changes in these and we take the

appropriate measures to get them back in a healthy range. Gum measurements are as

important to me. They tell me the health of my gums.”

Patient 65 (female, age 49): “Yes, in the past at other hygiene visits not much was told to me

about what the numbers mean and how I could change those numbers for better dental care.

Now I never want to leave the office without my measurements. I feel as though I am in a

partnership for my dental care.”

Patient 77 (male, age 35): “Yes, visual aids are beneficial. Making the > 4 numbers red and

also a picture of tooth and gum anatomy makes a greater impact. Knowing that the bone

wears away permanently is frightening and motivating to improve oral care.”

Patient 25 (male, age 45): “Yes, understanding gum measurements are helpful to me because

it gives me an indication of the health status of my gums. The measurements fluctuate and

understanding what is a normal, healthy range is important. This is similar to understanding

what a blood pressure reading means. There are normal healthy ranges and those ranges

that should be noted for alarm. Untreated blood pressure readings could cause serious health

problems just like untreated high numbers can cause serious gum and health problems.”

Patient 40 (male, age 73): “No, I don’t care. But I know Laurie wants the numbers so she

has the information to do a good job.”


Patient YES Responses # of Patients

Floss more 31

Brush bad areas more 28

Brush longer 26

Increased brushing frequency 23

Waterpik 20

Electric brush 16

Fluoride prescription 8

More frequent prophylaxis 8

Changed brush more often 4

Mouthwash 3

Oil pulling 2

Toothpick use 1

Change toothpaste 1

Air flosser 1

Patient NO Responses # of Patients

Numbers are already good, do not need to change 4

Lazy, not motivated, try but go back to old ways 3


Patient-Responses

Do You Change Your Home Care Regime Because Of Gum Measurements?

Patient 3 (male, age 45): “No. You try to, but I tend to go back to my normal routine.”

Patient 27 (female, age 31): “Yes I do. If the results are in the high range (4 or 5) then I know I

need to brush better, or floss more, or even to slow down when doing both. If they are low (1

or 2) then I know I am doing something right and should stick to it. I do not think that I would

take the time to really ensure that proper hygiene has taken place without these

measurements, they allow me to know where I stand at all times.”

Patient 78 (female, age 68): “Yes, if my measurements are over a 3 then I know I have work to

do. It helps me to be more diligent in dental flossing and using the waterpik.”

Patient 83 (male, age 61): “Previous to my last Hygiene visit, I was aware of gum

measurements but did not thoroughly understand them. After discussions with my present

Hygienist, I am better educated and now performing better oral care. I feel I can take

appropriate actions that can slow the progression of what could be causing the gum

measurements to worsen.”

Patient 28 (female, age 52): “I have never had gum measurements until I came to this dental

office. It made me more aware of how I am taking care of my teeth and gums (or lack of) and

has educated me on home care. I brush twice a day and floss at night. I am also going to get

a waterpik. For me the gum measurements are very important, I have been on the border of

gum disease.”

Patient 13 (female, age 50): “Yes, because I want to have a healthy mouth so I will do what I

am told to do by my hygienist.”

If it were only that easy!


Patient-

Responses

Patient 11 (male, age 49): “Yes, it is a tangible and measureable marker communicating my

gum health. It helps me gauge how I am doing relative to a simpler and general statement.”

Patient 58 (female, age 36): “I used to get worried about gum measurements until I realized

they are a tool to help me improve my oral health. So, though some people don’t like knowing

bad news, I personally feel education is how we realize we need improvement, and when the

news is good (‘1’ and ‘2’ measurements) I know I’m on the right track and that gives one

confidence to smile.”

Patient 43 (male, age 34): “In our society, numbers are what we as people identify with.

Whether in school, we want to know if we got a 80% or 90% or 100% on a test. If in business,

how much profit did we make? If any of these numbers decrease, it triggers (or should) that

competitive part of us that strives to perform or do better. The number (gum measurements)

will make us do better. Of course, we will compare to the last visit to see if we improved or not.

Without a number (measurement) I don’t think I would try as hard as I have nothing to compare

or strive for.”

100%

Do You Want Gum Measurements At Future Hygiene Visits?

YES


Believing I was having an impact through patient education I have provided periodontal probe

readings at every hygiene visit for 28 years. I feel the preceding research data confirms that

my efforts are making a difference in patient’s lives.

It was interesting that many patients said gum measurements are an important healthcare

number, placing equal value with blood pressure, cholesterol and weight measurements.

When asked, some patients were not able to explain exact details about any of these

measurement categories. However, they had an understanding of what numbers or gum

measurements were ‘good’ or ‘bad’ and strived for ‘good’.

I have presented periodontal probe readings as a health related service so I was

disappointed to see few patients talking about the link between periodontitis and health

problems such as diabetes, heart disease, premature births and rheumatoid arthritis.

Because of these disclosures, I am going to change my practice. More open ended

questions will be incorporated to determine each patient’s level of understanding and how I

can customize materials to fit their need. I will continue to use and review the patient’s

personal periodontal diagram because it has laid a beneficial foundation. However a patient

education menu including brochures and I-Pad presentations highlighting probe readings/gum

measurements, oral health/disease, impact of periodontal disease on overall health, home

care choices with instructions and treatment procedures will be introduced at the beginning of

hygiene visits. This quick-check menu will remain with the patient’s chart for future reference

and will include a section to note which take-home hygiene aids are recommended,

demonstrated and purchased. Education materials can be viewed during the prophylaxis.

Quiet Please, will be a choice on the menu if patients want to relax and listen to headphones.


There has been a process of change in my patient’s home care based on their gum

measurements. I was moved that knowledge I conveyed to them was deemed valuable

enough to become their own knowing that transmitted to action. There is no one size fits all

home care action-package so I was excited to see the varying strategies being implemented.

Even if my patients use an unconventional home care strategy, we will learn together if their

approach is successful for them.

I believed patients wanted periodontal probe readings, but was surprised 100% wanted to

continue receiving them. When asked if she wanted gum measurements at future hygiene

visits a 23 year old patient said, “If the hygienist wants me to.” Understanding the important

role I play in my patient’s hope for periodontal health is a responsibility and a privilege.

--------------------------------------------BUSINESS ASPECT-----------------------------------------------------

Patients are often unaware of problems lurking in their mouths and rely on the hygienist’s

expertise to inform and treat them. If patients come in for their regular 6 month prophylaxis

and find out they have tooth threatening pockets that no one told them about they may be

angry enough to call an attorney or at the very least share their negative experience with

anyone who will listen. So using probe readings for proper diagnosis and treatment will make

the patient happy and healthy, keep the dental office out of court and protect its reputation. A

great reputation builds the practice.

I have personally found that periodontal probe readings save time. As I explain what the

numbers mean, I am setting the stage for one or more hygiene visits. When there is too much

calculus and inflammation, the probe readings support the recommendation for additional

appointments. This will build the hygiene schedule and increase profitability. Having the

patient assist by writing their numbers is an additional time saver if an assistant is unavailable.


When employers see that this service has value, it opens the door for further discussion on

increased time allotted for hygiene appointments.

Probe readings are the foundation for treatment planning and lead to production. The patient

is aware they are overdue for their visit or have been remiss with their home care. So they are

not surprised when I acknowledge this and explain why any pocket beyond 3 millimeters with

bleeding may require additional treatment and adjunctive home care products. Another

prophylaxis, root planing or crown replacement, where an ill-fitting margin is aggravating a

pocket, will fill the hygienist’s and dentist’s schedules. Begin tracking scheduled procedures

and hygiene products patients are accepting and present this data to your employer. This

hygienist becomes a practice asset that could warrant increased financial compensation.

Charts 3, 4 and 5: Hygiene production from the 100 survey participants

Chart 3

Re-care

# of Patients

2 months 2

3 months 58

4 months 4

6 months 36

Chart 4 Hygiene Services

# of Patients

Root Planing 43

Periodontal Maintenance

43

Laser Bacterial Reduction

26

Fluoride Varnish 19

Chart 5 Hygiene Products

# of Patients

Prescription Fluoride

70

Chlorhexidine 52

Electric Brush 44

Waterpik 29


Personal Periodontal Diagrams include hygiene/dental

services and products that increase production.

Figure 3:

On left: *For individuals with healthy gums I propose 3-6

month prophylaxis depending on the level of stain and

supra-gingival calculus.

On right: *I suggest patients with gingivitis have 3-4 month

prophylaxis due to buildup, sensitivity, health or other special

concerns, implants or orthodontic appliances.

Figure 4: Recession (exposure of the root surfaces)

* I advocate an electric brush used with gentle pressure,

fluoride varnish, prescription fluoride gel or

dentifrice for root sensitivity or root caries prevention,

tissue grafting by the periodontist or a white filling done as

a protective barrier by the general dentist. (composite)

Figure 5: Root Planing (the removal of plaque, calculus

and toxin producing bacteria from root surfaces of patient

with periodontitis) *I advise 1-6 appointments with the

hygienist for root planing, laser bacterial reduction and site

specific antibiotic therapy, 2-3 month periodontal

maintenance re-cares and referral to periodontist after

tissue conditioning for evaluation of bone loss between

the roots. (furcation)


My study has shown me when patients are educated about the value of probe readings and

included in self-diagnosis, they want the measurements. Periodontal probe readings offer a

WOW factor! Not all offices provide this service at every visit. Patients appreciate exemplary

care and often want to see the same hygienist at their next re-care appointment, building

his/her schedule. This protocol can be duplicated, filling days for an additional hygienist. The

hygiene department is the backbone of the successful dental practice. Impressed patients will

refer friends and family, this is a win-win for patient, hygienist and dentist.

--------------------------------------------------CONCLUSION-------------------------------------------------------

One of my core values as a dental hygienist is developing periodontal probe readings at every

hygiene visit as a tool for patient education, home care improvement and treatment

acceptance. My objective in this study was to see if my patients shared this value. Patients

confirmed that gum measurements are helpful for them (99%) and made home care changes

based on these measurements (93%). One hundred percent of patients surveyed wanted to

receive gum measurements at future visits. One patient said, “For anyone with gum issues,

consistent measurements and current feedback are vital to continued gum health.” My

patients have spoken, so I believe it is worthwhile to continue my practice of providing

periodontal probe readings/gum measurements at every hygiene visit and to recommend this

practice to other hygienists.


----------------------------------------------------REFERENCES-----------------------------------------------------

Carranza, F., Takei, H. and Newman, M. (2002), Carranza’s Clinical Periodontology. 9th ed.

Philadelphia: Saunders.

Carranza, F., Takei, H., Newman, M. and Klokkevold, P. (2006), Carranza’s Clinical

Periodontology. 10th ed. St. Louis: Saunders.

McNiff, J. and Whitehead, J. (2011), All You Need To Know About Action Research. 2nd ed.

London: Sage.

Thornton-Evans, G., Eke, P., Wei, L., Palmer, A., Moeti, R., Hutchins, S. and Borrell, L. (2013),

Periodontitis Among Adults Aged > 30 Years - United States, 2009-2010. Centers For Disease

Control and Prevention. [online] Available at:

www.cdc.gov/mmwr/preview/mmmwrhtml/su6203a21.htm [Accessed 15 April 2014]

http://www.cdc.gov/mmwr/preview/mmmwrhtml/su6203a21.htm

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Do Patients Feel Gum Measurements, At Hygiene Visits, Are ... · 3 Do Patients Feel Gum Measurements ,At Hygiene Visits Are Helpful For Them? 2011, p.36) Patients may be at a fork