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Periodontics prep manual for ug.sample chapter-clinical and radiographic diagnosis. To order call us at +91 8527622422
 

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Periodontics prep manual for ug.sample chapter-clinical and radiographic diagnosis. To order call us at +91 8527622422 Periodontics prep manual for ug.sample chapter-clinical and radiographic diagnosis. To order call us at +91 8527622422 Document Transcript

  • UNIT VI Diagnosis, Prognosis and Treatment Plan23. Clinical and Radiographic Diagnosis.indd 233 19/11/11 2:29 PM
  • 23. Clinical and Radiographic Diagnosis.indd 234 19/11/11 2:29 PM
  • Clinical and C H A P T E R 23 Radiographic Diagnosis TERMINOLOGY/DEFINITION Diagnosis: The word diagnosis is derived from two root words, diag (to know) and osis (condition). It can be defined as the process of identifying the disease by its signs, symp- toms and results of various biologic assessments. Increased tooth mobility: It is expressed in terms of amplitude of displacement of the crown of the tooth and is usually observed in conjunction with trauma from occlusion. Lamina dura: The interdental bone normally is outlined by a thin, radiopaque line adja- cent to the periodontal ligament (PDL) and at the alveolar crest, referred to as the lamina dura. Because lamina dura represents the cortical bone lining the tooth socket, the shape and position of the root and changes in the angulation of the x-ray beam produce consider- able variations in its appearance. Long junctional epithelium: It refers to the adaptation and adherence of the junctional epithelium to the root surface following various therapeutic procedures, which apparently can be maintained for the many years without any regrowth of the bone. This type of wound healing is also known as ‘locus minoris resistentiae’. This clinical phenomenon is considered to be ‘repair’ and not new attachment. Periodontometers or mobilometers: These are mechanical or electronic devices for the precise measurement of tooth mobility. Progressive (increasing) tooth mobility: It can be identified only through a series of repeated tooth mobility measurements carried out over a period of several days or weeks. Pull syndrome (tension test): The detaching movement of marginal gingiva and interdental papilla transferred from the lip by the frenum when a slight pull is placed on the lip. QUESTIONS AND ANSWERS Q1. What are the various steps in diagnosing periodontal conditions? Answer: The initial comprehensive periodontal examination typically takes about 30–60 minutes and requires several steps to arrive at an accurate diagnosis. The comprehensive examination should include an evaluation of soft tissue, bleeding and exudate on probing, probing depths, gingival recession, mobility, furcation involvement, and an occlusal analysis along with temporomandibular disorder assessment. In addition, all secondary aetiologic factors that may harbour plaque—such as faulty margins and improperly contoured23. Clinical and Radiographic Diagnosis.indd 235 19/11/11 2:29 PM
  • Unit VI – Diagnosis, Prognosis and Treatment Plan 236 Figure 23.1 Flowchart showing steps in periodontal diagnosis crowns—should be identified and scheduled for restoration in the form of a treatment plan. Evaluation of a complete series of diagnostic periapical and bitewing radiographs is necessary for diagnosis and treatment planning. A panoramic radiograph may be necessary, especially when creating a treatment plan for dental implants or when impacted third molars are present. Figure 23.1 depicts a flow chart of the steps in periodontal diagnosis. Q2. What is the importance of diagnosing the periodontal condition? Answer: Diagnosing the periodontal condition helps in the following: ■ To find out the disease and severity of the disease. ■ For easy communication amongst clinicians. ■ For the development of well-designed and appropriate treatment plan. ■ For ascertaining the prognosis of the particular condition. Q3. What is the importance of recording medical history? Answer: The importance of medical history should be explained to the patient because they often omit information that they cannot relate to their dental problem. The systemic history will aid the clinician in the following: ■ The diagnosis of oral manifestations of any systemic disease. ■ The detection of systemic conditions that may be affecting the periodontal tissue response to local factors. ■ The detection of systemic conditions that require special precautions and modification in dental treatment procedures, e.g. infective endocarditis.23. Clinical and Radiographic Diagnosis.indd 236 19/11/11 2:29 PM
  • Chapter 23 – Clinical and Radiographic Diagnosis 237 Q4. What are the various symptoms in patients with gingival and periodontal disease? Answer: Following are some of the symptoms in patients with gingival and periodontal disease: ■ Bleeding gums. ■ Loose teeth. ■ Spreading of the teeth with the appearance of spaces where none existed before. ■ Foul taste in the mouth. ■ Itchy feeling in the gums, relieved by digging with a toothpick. There may also be pain of varied types and duration, as follows: ■ Constant dull gnawing pain. ■ Dull pain after eating. ■ Deep radiating pain in the jaws, especially on rainy days. ■ Acute throbbing pain. ■ Sensitivity to percussion. ■ Sensitivity to heat and cold. ■ Burning sensation in the gums. ■ Extreme sensitivity to inhaled air. Q5. What are the various generations of periodontal probes? Answer: Probes are the only reliable method of detecting periodontal pocket. The various generations of probes are listed in Table 23.1. Table 23.1 Generations of probes 1st 2nd 3rd 4th 5th generation generation generation generation generation probe probe probe probe probe Conventional Pressure-sensitive Automated probes, Aims at recording Would have an probes, probes, e.g. Vine- e.g. Florida probe, sequential probe ultrasound device e.g. Williams Valley probe, Viva Toronto automated positioned along attached to the probe, Merritt care TPS probe probe, Florida the gingival sulcus 4th generation A and B, Marquis, (Vivadent) PASHA probe etc. probe for UNC-15, WHO identifying probe, Goldman attachment Fox etc. level without penetrating it23. Clinical and Radiographic Diagnosis.indd 237 19/11/11 2:29 PM
  • Unit VI – Diagnosis, Prognosis and Treatment Plan 238 Q6. What is periodontal probing? Describe various factors affecting probing. Answer: The biologic depth is the distance between the gingival margin and the base of the pocket (the coronal end of the junctional epithelium). This can be measured only in carefully prepared and adequately oriented histologic sections. The probing depth is the distance to which an ad hoc instrument (probe) penetrates into the pocket. The depth of penetration of a probe, in a pocket depends on the following factors: ■ Size of the probe. ■ Force with which it is introduced. ■ Angulation or direction of penetration. ■ Resistance (inflammatory status) of the tissues. ■ Convexity of the crown. In general, the probe tip penetrates to the most coronal intact fibres of the connective tissue attachment. The depth of penetration of the probe in the connective tissue apical to the junctional epithelium in a periodontal pocket is about 0.3 mm. The probing forces of 0.75 N have been found to be well tolerated and accurate. Interexaminer error (depth discrepancies between examiners) was reported to be as much as 2.1 mm, with an average of 1.5 mm, in the same areas. Probing technique (walking probing, or stepping, or circumferential probing method) The probe should be inserted parallel to the vertical axis of the tooth and ‘walked’ circumferentially around each surface of each tooth to detect the areas of deepest penetration. To detect an interdental crater, the probe should be placed obliquely from both the facial and lingual surfaces so as to explore the deepest point of the pocket located beneath the contact point. The use of specially designed probes (e.g. Nabers probe) allows an easier and more accurate exploration of the horizontal component of furcation lesions. Transgingival, or trans-sulcular probing or sounding This procedure is performed under local anaesthesia. A periodontal probe is pushed through the gingiva tissue as a sounding device to determine the shape of the intrabony defects. Q7. What do you understand by ‘clinical attachment level’ and its significance? Answer: The ‘level of attachment’ is the distance between the base of the pocket and a fixed point on the crown, such as the CEJ. Changes in the level of attachment can be only due to gain or loss of attachment and can afford a better indication of the degree of periodontal destruction. When the gingival margin is located on the ana- tomic crown, the level of attachment is determined by subtracting from the depth of the pocket the distance from the gingival margin to the CEJ. If both are the same, the loss of attachment is zero. When the gingival margin coincides with the CEJ, the loss23. Clinical and Radiographic Diagnosis.indd 238 19/11/11 2:29 PM
  • Chapter 23 – Clinical and Radiographic Diagnosis 239 of attachment equals the pocket depth. When the gingival margin is located apical to the CEJ, the loss of attachment is greater than the pocket depth, and therefore the distance between the CEJ and the gingival margin should be added to the pocket depth. Drawing the gingival margin on the chart where pocket depths are entered helps clarify this important point. Q8. What are the various methods of checking aberrant frenum attachment? Answer: Placek et al described a morphologic functional classification of labial frenum attachment as follows: 1. Mucosal. 2. Gingival. 3. Papillary. 4. Papilla-penetrating attachment. Aberrant or high frenum is a problem of inadequate attached gingiva, and mandibular frenum is of no clinical significance if an adequate zone of attached gingiva is present coronal to frenum but maxillary frenum may present aesthetic problems or compromised orthodontic results. Two methods to check abnormal frenum attachment are as follows: a. Tension test: Lip is moved outwards, upwards for the upper, and downwards for the lower and also moved sidewards. If the marginal and oblique or interdental papilla moves away from the tooth surface, then tension test is said to be positive. b. Blanch test: It is performed to diagnose a fleshy labial frenum. It is done by pulling the upper lip outwards. Presence of thick and fleshy frenum is confirmed by the blanching of the tissue in the incisive papilla region. Q9. What do you understand by inadequate depth of the vestibule? Answer: Normal depth of the vestibule helps in proper maintenance of oral hygiene and also the movement of the food during mastication. Depth of the vestibule should be considered inadequate if the patient finds difficulty in placing the head of the toothbrush properly in the vestibule while brushing. Examination of the patient’s toothbrush size indicates about the inadequacy of the vestibule depth. Clinical parameters such as abnormal (high) frenal attachment also preclude the proper placement of the toothbrush. Q10. Enumerate the various methods of detecting mucogingival junction. Answer: The following methods can be employed for the detection of mucogingival junction: ■ Roll’s method: Clinically, a probe is placed horizontally, flat against the mucosal surface and sliding it coronally; this results in blanching of gingiva when the mucogingival junction is reached.23. Clinical and Radiographic Diagnosis.indd 239 19/11/11 2:29 PM
  • Unit VI – Diagnosis, Prognosis and Treatment Plan 240 ■ By applying chemicals (Schiller’s potassium iodide (KI) or Lugol’s solution) to stain the mucosa and attached gingiva: These solutions stain the glycogen content of the tissue and glycogen is more in alveolar mucosa than in the attached gingiva, because glycogen is utilized for the process of keratinization. As alveolar mucosa has high glycogen content it gives an iodine positive reaction, the mucogingival junction can thus also be visualized by using Lugol’s iodine solution. Q11. What are the various methods to measure attached gingiva? Answer: For clinical purposes, attached gingiva is defined as gingiva that is extending from the free margin of the gingiva to the mucogingival line, minus the pocket or sulcus depth measured with a thin probe in the absence of inflammation. It should have minimum width to prevent marginal retraction during facial movements, support the gingival fibres, and restorations. Adequate or inadequate attached gingiva in an individual is a clinical decision, and not mathematical, but can be detected by the tension test. Q12. What are black triangle/loss of interdental papilla? Answer: Interproximal contact between the maxillary incisors consists of two parts: the tooth contact and papilla, with papilla:tooth contact ratio of 1:1. Recession of the gingival tissue from the interproximal areas, leaving behind a space can be termed as loss of inter- dental papilla or creation of black triangle. Its aetiological factors are: a. Loss of periodontal support due to plaque associated lesions. b. Abnormal tooth shape. c. Improper contours of prosthetic restorations. d. Traumatic oral hygiene procedures. Q13. What are the various wasting diseases? Answer: Wasting is defined as any gradual loss of tooth substance characterized by the formation of smooth, polished surfaces, without regard to the possible mechanism of this loss. The forms of wasting are erosion, abrasion, attrition and abfraction. a. Erosion (corrosion, cuneiform defect) is a sharply defined wedge-shaped depression in the cervical area of the lingual and facial tooth surface. The long axis of the eroded area is perpendicular to the vertical axis of the tooth. The surfaces are smooth, hard, and polished. Erosion generally affects a group of teeth. Possible aetiology includes decalcification by acid beverages or citrus fruits, along with the combined effect of acid salivary secretion and friction. Such defects may also be seen in patients with gastrointestinal regurgitation problems and patients of anorexia nervosa. Sognnaes (1977) refers to these lesions as dentoalveolar ablations and attributes them to forceful frictional actions between the oral soft tissues and the adjacent hard tissues. In patients with erosion, the salivary pH, buffering capacity, and calcium and phosphorus content have been reported as normal with the mucin level elevated. b. Abrasion is the loss of tooth substance induced by mechanical wear other than that of mastication, such as horizontal tooth brushing and abrasive dentifrices, that result in23. Clinical and Radiographic Diagnosis.indd 240 19/11/11 2:29 PM
  • Chapter 23 – Clinical and Radiographic Diagnosis 241 saucer-shaped or wedge-shaped indentations with a smooth, shiny surface. Abrasion starts on exposed cementum surfaces rather than on the enamel and extends to involve the dentin of the root. A sharp ‘ditching’ around the CEJ appears due to the softer cemental surface, as compared with the much harder enamel surface. Habits such as holding objects (e.g. a bobby pin or tacks) may also cause abrasion of incisal edges of incisors. c. Attrition is occlusal wear resulting from functional contacts with opposing teeth due to bruxism and clenching etc. (Broca’s classification of attrition). The severity and magnitude of attrition was measured in patients’ mouths and on the study casts using Broca’s classification, 1897 (cited by Jacobson in 1972). 0 No attrition, tooth form retained. 1 Enamel worn without cusp obliteration or exposure of dentine. 2 Cusp worn down and dentine exposed. 3 A further stage in which quite an appreciable amount of crown of tooth is worn away. 4 An extreme stage in which most of the crown has disappeared and wear has extended to the neck of tooth. d. Abfraction results from occlusal loading surfaces causing tooth flexure and mechanical microfractures and tooth substance loss in cervical area. Q14. What is the importance of casts in making periodontal diagnosis? Answer: While making periodontal diagnosis, casts have the following significance: ■ Casts indicate position of gingival margin, inclination of teeth, proximal contact relationship and food impaction areas. ■ They provide a realistic view of lingual cuspal relationship. ■ Casts are important records of the dentition before and after the treatment. ■ Casts serve as visual aids in discussion with the patient and are useful for pre treatment and post treatment comparisons. Q15. Classify and diagnose tooth mobility. Add a note on periotest Answer: Refer to Q 11, chapter 20. Periotest The periotest device measures the reaction of periodontium to a defined percussion force which is applied to tooth and delivered by a tapping instrument. A metal rod is accelerated to a speed of 0.2 m/s with the device and maintained at a constant velocity. Upon impact, the tooth is deflected and rod decelerated. Contact time between tapping head and tooth varies between 0.3–2 milliseconds and is shorter for stable than mobile teeth. The periotest values correlate well with: (1) tooth mobility assessed with a metric system, and (2) degree of periodontal disease and alveolar bone loss. The periotest scale (periotest values) ranges from –8 to +50.23. Clinical and Radiographic Diagnosis.indd 241 19/11/11 2:29 PM
  • Unit VI – Diagnosis, Prognosis and Treatment Plan 242 Q16. What is the significance of sensitivity to percussion? Answer: Sensitivity to percussion is a feature of acute inflammation of the periodontal ligament. Vertical percussion along the long axis of the tooth generally indicates peri- apical inflammation. Horizontal or oblique percussion perpendicular to the long axis of the tooth indicates inflammation of the periodontal ligament. However, endo-perio lesions may be sensitive to percussion in both directions. Q17. How will you determine disease activity? Answer: Currently, no sure clinical methods exist to determine activity or inactivity of the lesion. Clinically, inactive lesion may show little or no bleeding on probing (BOP); the bacterial flora would consist of cocci cells. Contrary to this, active lesions bleed more readily on probing; bacterial flora shows greater number of spirochaetes and motile bacteria and have large amount of fluid and exudate. Although BOP may have a limited predictive value for disease progression, its absence indicates periodontal stability with high probability. One of the correct ways to determine disease activity at a particular site is to assess the probing attachment level changes between two or multiple examination intervals. If the particular site is losing attachment over a period of time, then that site is considered to be active. Q18. How is pus discharge from a pocket determined? Answer: Clinically, the presence of pus in a periodontal pocket is determined by placing the ball of the index finger along the lateral aspect of the marginal gingiva and applying pressure in a rolling motion towards the crown. This procedure is often termed as milking of gingiva. Q19. Enumerate the criteria to determine adequate angulation of periapical radiography. Answer: Prichard’s (1972) criteria for determining adequate angulation of periapical radiography include the following: 1. Tips of molar cusps with little or none of the occlusal surface should be visible. 2. Enamel caps and pulp chamber should be distinct. 3. Interproximal spaces should be open. 4. Proximal contacts should not overlap. Q20. What are the radiographic changes in periodontal diseases? Answer: The radiograph shows the amount of remaining bone rather than the amount lost. The amount of bone lost is estimated to be the difference between the physiologic bone level of the patient and the height of the remaining bone, thus detected by the indi- rect method. Difference between alveolar crest height and the radiographic appear- ance ranges from 0 to 1.6 mm, mostly accounted for by X-ray angulation. Radiographic changes in periodontal diseases include the following:23. Clinical and Radiographic Diagnosis.indd 242 19/11/11 2:29 PM
  • Chapter 23 – Clinical and Radiographic Diagnosis 243 Chronic periodontitis ■ Fuzziness and break in continuity of lamina dura at mesial/distal aspect of the crest of interdental septum have been considered as the earliest radiographic changes in periodontitis. ■ Wedge-shaped radiolucent area is formed at mesial or distal aspect of crest of septal bone, apex of the area is pointed in direction of root in periodontitis. ■ Height of crest of the interdental septum is reduced. ■ Horizontal bone loss: The radiographic appearance of loss in height of alveolar bone around multiple teeth is horizontal (parallel with occlusal plane) but is positioned more apically, more than a few millimetres from the line of the CEJ. Bone is reduced in height, but the bone margins remain roughly perpendicular to the tooth surface. Aggressive periodontitis ■ Bone loss in aggressive periodontitis is typically vertical. ■ Pattern appears to be arc-shaped loss of alveolar bone. Initially it may involve the maxillary and mandibular incisors and/or first molar areas, usually bilateral. ■ In generalized form (when disease progresses), bone loss may be of vertical or angular and horizontal pattern, but less pronounced in premolar areas. Interdental craters ■ Concavities in the crest of interdental bone seen as irregular areas of reduced radiopacity on the alveolar bone with which they blend gradually. Radiographs do not accurately depict the morphology or depth of interdental craters which sometimes appear as vertical defects. Furcation involvement ■ Radiographs are useful but show artefacts that allow furcation involvement to be present without detectable radiographic changes. ■ Bone loss is always greater than it appears in the radiograph. ■ Variations in radiographic technique may obscure the presence and extent of furcation involvement, so radiograph should be taken at different angles to get a correct picture. ■ If sufficient bone loss has occurred on the lingual and buccal aspects of mandibular furcation, the radiolucent image of lesion becomes prominent. ■ Occasionally this pattern of bone destruction is prominent and it appears as the look of letter J, extending into trifurcation. ■ Slightest radiographic change in the furcation area should be investigated clinically. ■ Diminished radio density in the furcation area in which outlines of bony trabeculae are visible suggests furcation involvement. ■ Whenever there is marked bone loss in relation to the single molar root, it may be assumed that the furcation is also involved.23. Clinical and Radiographic Diagnosis.indd 243 19/11/11 2:29 PM
  • Unit VI – Diagnosis, Prognosis and Treatment Plan 244 Periodontal abscess The typical radiographic appearance of periodontal abscess is a discrete area of radiolucency along the lateral aspect of the root. The radiographic picture is often not typical because of many variables, such as the following: ■ The stage of the lesion. In early stages, the acute periodontal abscess is extremely painful but presents no radiographic changes. ■ The extent of bone destruction and the morphologic changes of the bone. ■ The location of the abscess. Lesions in the soft tissue wall of a periodontal pocket are less likely to produce radiographic changes than those deep in the supporting tissues. Abscesses on the facial or lingual surface are obscured by the radiopacity of the root; interproximal lesions are more likely to be visualized radiographically.23. Clinical and Radiographic Diagnosis.indd 244 19/11/11 2:29 PM