• CASE HISTORY
History of Presenting Complaint
Past Medical History
Past Dental History
• CLINICAL EXAMINATION
Intraoral Examination(soft tissues, hard tissues, periodontium)
• PERIODONTAL SCREENING AND RECORDING SYSTEM
• Treatment is secondary, the primary task for the clinician is to identify
the problem and find its etiology.
• Periodontal diagnosis should first determine whether dx is present;
then identify its type;, extent, distribution, and severity; and finally
provide an understanding of the underlying pathologic processes and
• Hence, the case history and clinical examination are essential in
diagnosing the periodontal diseases.
• Case history is the information gathered from the patient and/or
parent and/or guardian to aid in the overall diagnosis of the case.
• It includes certain personal details, the chief complaint, past and
present dental and medical history and any associated family history.
• Age/ Date of Birth
• Marital status
• address & occupation
• Race/ ethnicity
• The patient's chief complaint should be recorded in his or her own
• It should mention the condi-tions the patient feels he / she is
• E.g i have a swelling in my mouth,my gum is paining me,I feel pain in
my tooth when I eat.
History of the Presenting Complaint
Symptoms: Are subjective information reported by the patient. A report
of patient’s own sensory experience. These are usually the 1st aspects of
history to be recorded.
• Onset of complaint.
• Character of onset.
• Severity of the complaint.
• Course of complaint.
• Location of complaint.
• Prior occurrence.
• Exacerbating factors .
• Relieving factors .
• Associated phenomenon. Fever, bleeding, bad odour
Complication: consider whether speech, mastication, sleep or any
other function have been affected.
Treatment: Consider any previous treatment and their effectiveness.
Past Medical History
• Medical history puts physical examination into perspective by supplying
information that should alert the examiner to suspected abnormalities.
• Even in a life-threatening situation, once the immediate threat has been
contained, a history should be obtained from the patient.
• Recent hospitalization
• Endocrine disorder
• Gastrointestinal complaints
• Last blood glucose study
• Blood disorder
• Infection including HIV status
• Drug therapy
Past Dental History
• Frequency of visiting dentist and purpose of visit.
• Assessment of past caries experience, restorative dental procedures.
Administration of local anesthesia.
• Past oral surgical procedures, bleeding & healing process.
• Previous orthodontic treatment.
• Periodontal disease & previous periodontal treatment.
• History of denture wearing, cause of loss of teeth.
• Family history is taken to determine if there is a familial
predisposition to diseases or if there are diseases in which
inheritance is an important factor.
• The dentist should inquire specifically about a family history of
diabetes, cancer, heart disease, high blood pressure, seizure
disorders, mental disorders, and other diseases that may be
• Social history help explain untoward reactions to health problems
and to the therapeutic recommendations.
• For example, the alcoholic patient may be unwilling to follow
recommendations about diet and oral hygiene.
• Social history is therefore important in assessing whether a patient
is in a high-risk group, for example, those with alcoholism, drug
addiction, or contagious infections such as herpes, hepatitis,
tuberculosis, or AIDS.
• Oral hygiene habits: frequency & technique of tooth brushing &
• Habits as nail biting, thumb sucking.
• Parafunctional habits as bruxism, clenching & tapping.
• Smoking habit
• Consumption of CHO food:form,frequency
• Clinical examination consists of 3 main stages:
1. Observation of the patient’s general health and appearance.
2. Extraoral examination of the head and neck.
3. Examination of the intraoral tissues.
• Note problems such as:
1. Body weight/ fit of clothes
4. Exposed skin areas
5. Facial scarring
• Examine the face for facial assymetry.
• Check for bony discontinuity.
• TMJ examination for TMJ disorder
• Examine the submandibular lymph for lymphadenopathy.
• Examine the lip for competence,angular chelitis etc
• Examine for nerve dysfunction
• The entire oral cavity should be carefully examined.
• Soft tissue Examination: examine the mucosa of the lip, cheek, floor of the
mouth, tongue, gingiva and palate for:
• Hard tissue Examination: the teeth are examined for:
• developmental defect
• anomalies of tooth form & number
• Dental stains
• Proximal contact relationship.
• Mobility(physiologic or pathologic)
• Sensitivity to percussion
• Dentition with the jaw closed
Examination of the Periodontium
• The periodontal examination should be systematic, starting in the
molar region in either the maxilla or the mandible and proceeding
around each arch.
Plaque and calculus: the presence of supragingival plaque and
calculus can be directly observed and the amount measured with a
calibrated probe. For the detection of subgingival calculus , each
tooth surface is carefully checked to the level of the gingival
attachment with a sharp no.17 explorer.
Gingiva: consider the colour, size, contour, consistency, surface
texture, position, ease of bleeding, and pain. The distribution of
gingival disease and its acuteness or chronicity should also be noted.
Periodontal pockets: presence and distribution on each tooth surface,
pocket depth, level of attachment on the root, and type of
pocket(suprabony/ intrabony) must be considered.
Probing technique-the probe should be inserted paprallel to the
vertical axis of the tooth and ‘walked’ circumferentially around each
surface of each tooth to detect the area of deepest penetration.
Level of attachment vs pocket depth
• Pocket depth is the distance between the base of the pocket and the
gingival margin while level of attachment is the distance btw the base
of the pocket and a fixed point on the crown e.g. CEJ
• Pocket depth may be unrelated to the existing attachment of the
tooth while changes in level of attachment can be due only to gain or
loss of attachment and afford a better indication of periodontal
• Shallow pockets attached at the level of the apical 3rd of the root
connote more severe destruction than deep pockets attached at the
coronal 3rd of the roots.
Degree of gingival recession: the measurement is taken with a
periodontal probe from the CEJ to the gingival crest.
The Periodontal Screening and
Recording (PSR) System
• The PSR system is designed for easier & faster recording of the
periodontal status of a patient by a GP or a dental hygienist.
• It uses a specially designed probe that has a 0.5mm ball tip and is
colour coded from 3.5- 5.5mm.
• Patient mouth is divided into 6 sextants.
• Each tooth is probed, with the clinician walking the probe around the
tooth: MB, midB, DB, & the corresponding lingual/palatal areas.
• The deepest finding is recorded in each sextant along with other
findings, according to the following code:
• Code 0: No pockets >3.5 mm, no calculus/overhangs, no bleeding after
probing (black band completely visible)
• Code 1: No pockets >3.5 mm, no calculus/overhangs, but bleeding after
probing (black band completely visible)
• Code 2: No pockets >3.5 mm, but supra- or subgingival calculus/overhangs
(black band completely visible)
• Code 3: Probing depth 3.5-5.5 mm (black band partially visible, indicating
pocket of 4-5 mm)
• Code 4: Probing depth >5.5 mm (black band entirely within the pocket,
indicating pocket of 6 mm or more)
• Code *: Furcation involvement , tooth mobility, or gingival recession
extending to the colored band of the probe.
• Both the number and the * should be recorded if a
furcation/mobility/g. recession is detected - e.g. the score for a
sextant could be 3* (e.g. indicating probing depth 3.5-5.5 mm PLUS
furcation involvement in the sextant).
• The interest should be in the patient who has the disease and not
simply in the disease itself.
• Diagnosis must therefore include a general evaluation of the patient
and consideration of the oral cavity.
• Caranza’s Clinical Periodontology 9th edition
• Periodontal Medicine by Rose et al
• Article on BPE by British Society of Periodontology 2011
• Oral Diagnosis by Warren Birnbaum & Stephen Dunne