4_5785435455835080200_111501.pdf

DIAGNOSIS, PROGNOSIS, AND
TREATMENT PLAN
DR SAHAR ABDELATIF
ABELRHMAN
B.D.S, M.Sc (U of K)
HDLD(SUST)
DR SAHAR ABDELATIF ABDELRHMAN

OBJECTIVES
By the end of the lecture the students must be able :
1- To define diagnosis in clinical condition
2- To outline different method in diagnosis of periodontal
disease
1- To set individual tooth prognosis according to diagnosis
2- To correlate individual tooth prognosis to overall prognosis
3- To outline phases of treatment plan
4- To set treatment plan according to prognosis

LABORATORY AIDS TO CLINICAL DIAGNOSIS
Proper diagnosis is essential to intelligent treatment
Periodontal diagnosis should :
1) First determine whether disease is present
2) Identify its type
3) Extent
4) Distribution
5) Severity
6) Finally provide an understanding of the underlying pathologic processes
and its cause.

In general, they fall into the following three broad categories.
1) The gingival diseases.
2) The various types of periodontitis .
3) The periodontal manifestations of systemic diseases.

FIRST VISIT
1) Overall Appraisal of the Patient
This includes consideration of the patient's:
A. Mental and emotional status
B. Character
C. Attitude
D. Physiologic age.

2) Medical History
The health history can be obtained:
A. Verbally by questioning the patient .
B. Recording his or her responses on a blank piece of paper .
C. A printed questionnaire the patient completes.

MEDICAL HISTORY FORM FROM THE AMERICAN DENTAL ASSOCIATION.

The patient should be made aware of:
(1 ) The possible role that some systemic diseases, conditions, or
behavioural factors may play in the cause of periodontal disease.
(2) The presence of conditions that may require special
precautions or modifications in the treatment procedure.
(3) The possibility that oral infections may have a powerful
influence on the occurrence and severity of a variety of systemic
diseases and conditions.

The medical history should include reference to the following:
1) Is the patient under the care of a physician and if so, what is
the nature and duration of the problem and the therapy?
The name, address, and telephone number of the physician should
be recorded, since direct communication with him or her may be
necessary.

2 ) Details on hospitalizations and operations, including:
Diagnosis
Kind of operation
And untoward events, such as anesthetic, hemorrhagic, or
infectious complications .

3) A list of all medications being taken and whether they were
prescribed or obtained over-the-counter.
All the possible effects of these medications should be carefully
analyzed to determine:
A) Their effect, if any, on the oral tissues
B) To avoid administering medications that would interact
adversely with them.

Special inquiry should be made regarding the dosage and
duration of therapy with anticoagulants and corticosteroids.
Patients taking the family of drugs called bisphosphanates
(osteoporosis) osteonecrosis of the jaw after undergoing any
form of oral surgery involving the bone.

4) History should be taken of all medical problems
(cardiovascular, hematologic, endocrine, etc), including infectious
diseases, sexually transmitted diseases, and high-risk behavior for
human immunodeficiency virus (HIV) infection).
5) Any possibility of occupational disease should be noted.

6) Abnormal bleeding tendencies, such as nosebleeds, prolonged
bleeding from minor cuts, spontaneous ecchymoses, tendency
toward excessive bruising, and excessive menstrual bleeding,
should be cited.
These symptoms should be correlated with the medications the
patient is taking.

7) History of allergy including :
A. Hay fever
B. Asthma
C. Sensitivity to foods
D. Sensitivity to drugs (aspirin, codeine, barbiturates,
sulfonamides, antibiotics, procaine, and laxatives)
E. Sensitivity dental materials (eugenol or acrylic resins).

8) Information is needed regarding the onset of puberty and for
females, menopause, menstrual disorders, hysterectomy,
pregnancies, and miscarriages.
9) Family medical history should be taken, including bleeding
disorders and diabetes.

3) Dental History
A) Current Illness :
I. Bleeding gums
II. Loose teeth
III. Spreading of the teeth with the appearance of spaces where
none existed before
IV. Foul taste in the mouth
V. An itchy feeling in the gums, relieved by digging with a
toothpick.

B) Pain of varied types and duration, including:
I. Constant, dull, gnawing pain
II. Dull pain after eating
III. Deep, radiating pains in the jaws
IV. Acute throbbing pain
V. Sensitivity when chewing
VI. Sensitivity to hot and cold
VII. Burning sensation in the gums
VIII. Sensitivity to inhaled air.

A first oral examination is done to explore the source of the
patient's chief complaint and to determine whether immediate
emergency care is required.
If this is the case, the problem is addressed after consideration
of the medical history

The dental history should include reference to the following:
1) Visits to the dentist, including:
A. Frequency, date of the most recent visit
B. Nature of the treatment
C. Oral prophylaxis
D. Cleaning by a dentist or hygienist frequency and date of
most recent cleaning.

2) The patient's oral hygiene regimen, including:
A. Toothbrushing frequency, time of day, method
B. Type of toothbrush and dentifrice
C. Interval at which brushes are replaced.
D. Other methods for mouth care, such as mouthwashes,
interdental brushes or other devices, water irrigation, and
dental floss.
3) Any orthodontic treatment, including duration and
approximate date of termination.

4) If the patient is experiencing pain in the teeth or in the
gingiva:
A. The manner in which the pain is provoked
B. Its nature and duration
C. The manner in which it is relieved.

5) Gingival bleeding, including:
A. When first noted
B. Whether it occurs spontaneously, on brushing or eating, at night, or
with regular periodicity
C. Whether it is associated with the menstrual period or other specific
factors
D. Duration of the bleeding
E. The manner in which it is stopped.
6) A bad taste in the mouth and areas of food impaction

7) Do the teeth feel “loose” or insecure?
A. Is there difficulty in chewing?
B. Any tooth mobility should be recorded.

8) The patient's general dental habits such as:
A. Grinding or clenching of the teeth during the day or at night.
B. Do the teeth or jaw muscles feel “sore” in the morning?
C. Are there other habits such as tobacco smoking or chewing,
nail biting, or biting on foreign objects?

9) History of previous periodontal problems, including :
A. The nature of the condition
B. If previously treated, the type of treatment received (surgical or
nonsurgical)
C. Approximate period of termination of previous treatment.
D. If, in the opinion of the patient, the present problem is a recurrence
of previous disease, what does he or she think caused it?

10) Does the patient wear any removable prosthesis?
Does the prosthesis enhance or is it a detriment to the existing
dentition or the surrounding soft tissues?
11) Does the patient have implants replacing any of the missing
teeth?

4) Intraoral Radiographic Survey
The radiographic survey should consist of a minimum of 14
intraoral films and four posterior bite-wing films.

FULL-MOUTH INTRAORAL RADIOGRAPHIC SERIES (16 PERIAPICAL FILMS AND
FOUR BITE-WING FILMS) USED AS AN ADJUNCT IN PERIODONTAL DIAGNOSIS

Panoramic radiographs are a simple and convenient method of obtaining a
survey view of the dental arch and surrounding structures .
They are helpful for the detection of:
1) Developmental anomalies
2) A pathologic lesions of the teeth and jaws
3) Fractures
4) Dental screening examinations of large groups.
5) Distribution and severity of bone destruction in periodontal disease.
But a complete intraoral series is required for periodontal diagnosis and
treatment planning.

PANORAMIC RADIOGRAPH SHOWING TEMPOROMANDIBULAR JOINTS AND “CYSTIC” SPACES IN
THE JAW. AREAS OF PERIODONTAL BONE LOSS ARE NOT SEEN IN DETAIL.

5) Casts
Casts from dental impressions are useful adjuncts in the oral
examination.
They indicate the:
A. Position of the gingival margins (recession)
B. The position and inclination of the teeth
C. Proximal contact relationships
D. Food impaction areas.
E. Provide a view of the lingual-cuspal relationships.

F. Casts are important records of the dentition before
it is altered by treatment.
G. Serve as visual aids in discussions with the patient
and are useful for pretreatment and posttreatment
comparisons, as well as for reference at recall visits.
H. Helpful to determine the position of implant
placement if the case will require their use.

6) Clinical Photographs
Color photographs are useful for recording the appearance of the
tissue before and after treatment.
Photographs cannot always be relied on for comparing subtle
color changes in the gingiva, but they do describe gingival
morphologic changes.
With the advent of digital clinical photography, record
keeping for mucogingival problems, such as areas of gingival
recession, frenum involvement, and papilla loss, has become
important

7) Review of the Initial Examination
If no emergency care is required, the patient is dismissed and
instructed as to when to report for the second visit.
Before this visit, a correlated examination is made of the
radiographs, photographs, and casts to relate the radiographic
changes to unfavourable conditions represented on the casts.

The radiographs, photographs, and casts are valuable diagnostic
aids  it is the clinical findings in the oral cavity that constitute the
basis for diagnosis.

SECOND VISIT
1) Oral Examination
a) Oral Hygiene
The cleanliness of the oral cavity is appraised in terms of the
extent of accumulated food debris, plaque, and tooth surface
stains .
Disclosing solution to detect unnoticed plaque .
The amount of plaque detected is not necessarily related to
the severity of the disease present (Aggressive periodontitis).

POOR ORAL HYGIENE. GINGIVAL INFLAMMATION ASSOCIATED WITH PLAQUE,
MATERIA ALBA, AND CALCULUS.

B) Oral Malodor
Mouth odors may be of diagnostic significance, and their origin
may be either oral or extraoral (remote).

c) Examination of the Oral Cavity
The examination should include the lips, floor of the mouth, tongue,
palate, and oropharyngeal region, as well as the quality and
quantity of saliva.
The dentist should detect all pathologic changes present in the
mouth.

2) Examination of Lymph Nodes
Because periodontal, periapical, and other oral diseases may
result in lymph node changes, the diagnostician should routinely
examine and evaluate head and neck lymph nodes.
Lymph nodes can become enlarged and/or indurated as a
result of an infectious episode, malignant metastases, or residual
fibrotic changes.
Inflammatory nodes become enlarged, palpable, tender, and
fairly immobile.

The overlying skin may be red and warm.
Patients are often aware of the presence of “swollen glands.”
Primary herpetic gingivostomatitis, necrotizing ulcerative gingivitis
(NUG), and acute periodontal abscesses may produce lymph
node enlargement.
After successful therapy, lymph nodes return to normal in a matter
of days or a few weeks.

3) Examination of the Teeth and Implants
The teeth are examined for :
A. Caries
B. Poor restorations
C. Developmental defects
D. Anomalies of tooth form
E. Wasting, hypersensitivity
F. Proximal contact relationships.

The implant are examined for:
A. The stability
B. Position
C. Number of implants
D. Their relationship to the adjacent natural dentition

WASTING DISEASE OF THE TEETH
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:
1) Erosion
2) Abrasion
3) Attrition.

ABRASION ATTRIBUTED TO AGGRESSIVE TOOTH BRUSHING.
INVOLVEMENT OF THE ROOTS IS FOLLOWED BY UNDERMINING OF THE
ENAMEL.

OCCLUSAL WEAR. FLAT, SHINY , DISCOLORED SURFACES PRODUCED BY
OCCLUSAL WEAR.

Dental Stains
These are pigmented deposits on the teeth.
They should be carefully examined to determine their origin.
Hypersensitivity
Root surfaces exposed by gingival recession may be
hypersensitive to thermal changes or tactile stimulation.
Patients often direct the clinician to the sensitive areas.
These may be located by gentle exploration with a probe or cold
air.

Proximal Contact Relations
Open contacts allow food impaction.
The tightness of contacts should be checked by means of clinical
observation and with dental floss.
Teeth opposite an edentulous site may supererupt, thus opening
the proximal contacts.

Abnormal contact relationships may also initiate occlusal
changes such as:
1) A shift in the median line between the central incisors
2) Labial flaring of the maxillary canine, buccal
3) Lingual displacement of the posterior teeth

Tooth Mobility
All teeth have a slight degree of physiologic mobility,
which varies for different teeth and at different times of
the day.

Mobility is graded according to the ease and extent of tooth
movement as follows:
• Normal mobility
• Grade I: Slightly more than normal.
• Grade II: Moderately more than normal.
• Grade III: Severe mobility faciolingually and/or mesiodistally,
combined with vertical displacement

TOOTH MOBILITY CHECKED WITH A METAL INSTRUMENT AND ONE
FINGER.

Pathologic Migration of the Teeth
Alterations in tooth position should be carefully noted.
Contributing factors :
1) Abnormal forces
2) A tongue-thrusting habit, or other habits
3) Pathologic migration of anterior teeth in young persons may
be a sign of localized aggressive (juvenile) periodontitis.

PERIODONTAL DISEASE WITH PATHOLOGIC MIGRATION OF THE ANTERIOR
TEETH. A, CLINICAL PHOTOGRAPH. B, RADIOGRAPHIC VIEW.

Sensitivity to Percussion
Sensitivity to percussion is a feature of acute
inflammation of the periodontal ligament.
Gentle percussion of a tooth at different angles to
the long axis often aids in localizing the site of
inflammatory involvement.

Dentition with the Jaws Closed
Examination of the dentition with the jaws closed can detect
conditions, such as:
1) Irregularly aligned teeth
2) Extruded teeth
3) Improper proximal contacts
4) Areas of food impaction
5) Excessive overbite
6) Open-bite
7) Crossbite.

Functional Occlusal Relationships
Examination of functional occlusal relationships is an important
part of the diagnostic procedure.
Dentitions that appear normal when the jaws are closed may
present marked functional abnormalities.

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 the arch.
It is important to detect the earliest signs of gingival and
periodontal disease.
Charts to record the periodontal and associated findings provide
a guide for a thorough examination and record of the patient's
condition .
They are also used to evaluate the response to treatment and
for comparison at recall visits DR SAHAR ABDELATIF ABDELRHMAN

Electronic clinical records have been developed and are
increasingly being used by general dentists and periodontists.
Computerized dental examination systems using high-resolution
graphics and voice-activated technology permit easy retrieval
and comparison of data.

Plaque and Calculus
There are many methods available for assessing plaque and
calculus accumulation.
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
explorer.
Warm air may be used to deflect the gingiva and aid in
visualization of the calculus. DR SAHAR ABDELATIF ABDELRHMAN

TOP LEFT, DETECTION OF SMOOTHNESS OF VARIOUS IRREGULARITIES ON THE ROOT SURFACE WITH
OUTWARD MOTION OF A PROBE OR EXPLORER.

Although the radiograph may sometimes reveal heavy calculus
deposits interproximally and even on the facial and lingual surfaces, it
cannot be relied on for the thorough detection of calculus.

Gingiva
The gingiva must be dried before accurate observations can be
made .
Light reflection from moist gingiva obscures detail.
Visual examination and exploration with instruments, firm but
gentle palpation should be used for detecting pathologic
alterations in normal resilience, as well as for locating areas of
exudate.

Features of the gingiva to consider are: color, size, contour,
consistency, surface texture, position, ease of bleeding, and
pain .
Any deviation from the normal should be evaluated and not
ignored.
The distribution of gingival disease and its acute or chronic nature
.

Use of Clinical Indices in Dental Practice
There has been a tendency to extend the use of indices
originally designed for epidemiologic studies into dental
practice
The gingival index and the sulcus bleeding index appear to be
the most useful and most easily transferred to clinical practice.

The gingival index (Löe and Silness)
Provides an assessment of:
1) The gingival inflammatory status
2) Used in practice to compare gingival health before and after
phase I therapy or before and after surgical therapy.
3) Used to compare the gingival status at recall visits.

The sulcus bleeding index (Mühlemann and Son)
Provides an objective, easily reproducible assessment of the
gingival status.
It is extremely useful for detecting early inflammatory changes
and the presence of inflammatory lesions located at the base of
the periodontal pocket, an area inaccessible to visual
examination.
Patients can easily understand this index; therefore it can be
used to enhance the patient's motivation for plaque control.

Periodontal Pockets
Examination for periodontal pockets must include :
1) Their presence and distribution on each tooth surface,
2) Depth
3) Level of attachment on the root
4) Type of pocket (suprabony or infrabony).

Signs And Symptoms
Although probing is the only reliable method of detecting
pockets, clinical signs may also denote the presence of a
pocket.

PERIODONTAL POCKETS AROUND MANDIBULAR ANTERIOR TEETH, SHOWING ROLLED
MARGINS, EDEMATOUS INFLAMMATORY CHANGES, AND ABUNDANT CALCULUS AND
PLAQUE.

PERIODONTAL POCKET WITH VERTICAL DISCOLORED ZONE
EXTENDING TO THE ALVEOLAR MUCOSA

PERIODONTAL POCKET BETWEEN MAXILLARY CENTRAL INCISORS PRODUCED
BLUISH DISCOLORATION EXTENDING APICALLY . PROBING REVEALS PRESENCE OF
DEEP POCKET.

SEVERE GENERALIZED GINGIVAL INFLAMMATION. NOTE THE DARK HUE IN THE MARGINAL AREAS OF
THE CENTRAL INCISORS, WHICH IS CAUSED IN PART BY DARK SUBGINGIVAL CALCULUS AND A DEEP
POCKET.

Detection Of Pockets
The careful exploration with a periodontal probe.
Pockets are not detected by radiographic examination.
The periodontal pocket is a soft tissue change. Radiographs
indicate areas of bone loss in which pockets may be suspected.
Gutta percha points or calibrated silver points can be used
with the radiograph to assist in determining the level of
attachment of periodontal pockets

BLUNTED SILVER POINTS ASSIST IN LOCATING THE BASE OF POCKET.

Pocket Probing
There are two different pocket depths:
(1 ) The biologic or histologic depth
(2) The clinical or probing depth

A- Biologic or histologic pocket depth
is the actual distance between the
gingival margin and the attached
tissues (bottom of pocket).
B, Probing or clinical pocket depth is
the depth of penetration of the probe

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 a probe
penetrates into the pocket.

Probe penetration can vary, depending on:
1) The force of introduction
2) The shape and size of the probe tip
3) The direction of penetration
4) Resistance of the tissues
5) Convexity of the crown
6) The degree of tissue inflammation

A, In a normal sulcus with a long
junctional epithelium (between arrows),
the probe penetrates about one third to
one half the length of the junctional
epithelium.
B, In a periodontal pocket with a short
junctional epithelium (between arrows),
the probe penetrates beyond the
apical end of the junctional epithelium

In human periodontal pockets, the probe tip penetrates to the
most coronal intact fibers 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
This is important in evaluating differences in probing depth
before and after treatment, as the reduction in probe
penetration may be a result of reduced inflammatory response
rather than gain in attachment.
The probing forces ; Forces of 0.75 N(25 gm) have been found
to be well tolerated and accurate.

Probing Technique
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

“.
WALKING” THE PROBE TO EXPLORE THE ENTIRE POCKET

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 .
In multirooted teeth, the possibility of furcation involvement should
be carefully explored.
The use of specially designed probes (e.g., Nabers probe) allows
an easier and more accurate exploration of the horizontal
component of furcation lesions

.
VERTICAL INSERTION OF THE PROBE (LEFT) MAY NOT DETECT INTERDENTAL CRATERS; OBLIQUE
POSITIONING OF THE PROBE (RIGHT) REACHES THE DEPTH OF THE CRATER

Exploring with a
periodontal probe (left)
may not detect furcation
involvement; specially
designed instruments
(Nabers probe) (right)
can enter the furcation
area.

LEVEL OF ATTACHMENT VERSUS POCKET DEPTH
Pocket depth is the distance between the base of the pocket
and the gingival margin.
It may change from time to time even in untreated
periodontal disease because of changes in the position of
the gingival margin, and therefore it may be unrelated to the
existing attachment of the tooth.

The level of attachment, is the distance between the base of the
pocket and a fixed point on the crown such as the cementoenamel
junction (CEJ).
Changes in the level of attachment can be the result of gain or
loss of attachment and afford a better indication of the degree
of periodontal destruction (or gain).

DETERMINING THE LEVEL OF ATTACHMENT
When the gingival margin is located on the anatomic 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 loss 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.

BLEEDING ON PROBING
The insertion of a probe to the bottom of the pocket
elicits bleeding if the gingiva is inflamed and the pocket
epithelium is atrophic or ulcerated.
Noninflamed sites rarely bleed.
In most cases, bleeding on probing is an earlier sign of
inflammation than gingival color changes.

If periodontal treatment is successful, bleeding on probing
will cease.
To test for bleeding after probing, the probe is carefully
introduced to the bottom of the pocket and gently moved
laterally along the pocket wall.

Sometimes bleeding appears immediately after removal of the
probe; other times it may be delayed for a few seconds.
Therefore the clinician should recheck for bleeding 30 to 60
seconds after probing.
As a single test, bleeding on probing is not a good predictor of
progressive attachment loss; however, its absence is an excellent
predictor of periodontal stability.
When bleeding is present in multiple sites of advanced disease,
bleeding on probing is a good indicator of progressive
attachment loss.

WHEN TO PROBE
Probing of pockets is done at various times for diagnosis and for
monitoring the course of treatment and maintenance.
The initial probing of moderate or advanced cases is usually
hampered by the presence of heavy inflammation and abundant
calculus and cannot be done very accurately.

Probing at this stage is also difficult as the result of the
discomfort and pain that occurs when the gingival tissues are
inflamed.
The purpose of this initial probing, together with the clinical and
radiographic examination, is done to determine whether the tooth
can be saved or should be extracted.

After the patient has performed an adequate plaque
control for some time and calculus has been removed,
the major inflammatory changes disappear and an
accurate probing of the pockets can be performed.
The purpose of this second probing is to accurately
establish the level of attachment and degree of
involvement of roots and furcations.

Data obtained from this probing provides valuable information
for treatment decisions.
Later in periodontal treatment, probings are done to determine
changes in pocket depth and to ascertain healing progress after
different procedures.

PROBING AROUND IMPLANTS
Since periimplantitis can create pockets around implants,
probing around them becomes part of examination and
diagnosis.
To prevent scratching of the implant surface, plastic
periodontal probes should be used instead of the steel
probes used for the natural dentition

A, Limitations in periodontal probing.
B, Probing pressure caused by probe angulation, presence of subgingival
calculus, and presence of overhanging restorations.

AUTOMATIC AND ELECTRONIC PERIODONTAL PROBING
This method combines the advantages of a constant probing
force with precise electronic measurement and computer
storage of data, thus eliminating the potential errors associated
with visual reading and the need for an assistant to record the
measurements.

The Florida Probe System
Consists of a probe handpiece, digital readout, foot switch,
computer interface, and computer.
The end of the probe is 0.4 mm.

.
Automated periodontal probes:
Florida Probe System. Integration of direct electronic measurements
with constant probing force with computer storage and online data
readout

FLORIDA PROBE SYSTEM.
A, HANDPIECE FOR ASSESSING PROBING POCKET DEPTHS.
B, HANDPIECE FOR ASSESSING RELATIVE CLINICAL ATTACHMENT LEVELS.

The automatic probe appears to underestimate deep
probing depths but show less variability than conventional
probing.
The automatic probe also has the problem of providing little
tactile sensitivity thus making it more difficult to “walk” the
probe.
Other electronic systems, such as the Inter probe and the
Periprobe

DETERMINATION OF DISEASE ACTIVITY
Currently, there are no accurate methods to determine activity or
inactivity of a lesion.
Inactive lesions may show little or no bleeding on probing and
minimal amounts of gingival fluid.
Active lesions bleed more readily on probing and have large
amounts of fluid and exudates although active and nonactive sites
may show no differences in bleeding on probing, even in patients
with aggressive periodontitis.

For the determination of pocket depth or attachment levels to
provide information on whether the lesion is in an active or
inactive state, measurements taken at different times have to be
compared.
The precise determination of disease activity will have a direct
influence on diagnosis, prognosis, and therapy.
The goals of therapy may change, depending on the state of the
periodontal lesion.

AMOUNT OF ATTACHED GINGIVA
It is important to establish the relation between the bottom of the
pocket and the mucogingival line.
The width of the attached gingiva is the distance between the
mucogingival junction and the projection on the external surface
of the bottom of the gingival sulcus or the periodontal pocket.
It should not be confused with the width of the keratinized gingiva,
because the latter also includes the marginal gingiva

Shaded area shows the attached gingiva, which extends between the projection on
the external surface of the bottom of the pocket (A) and the mucogingival junction
(B). The keratinized gingiva may extend from the
mucogingival junction (B) to the gingival margin (C).

The width of the attached gingiva is determined by
subtracting the sulcus or pocket depth from the total width of
the gingiva (gingival margin to mucogingival line).
The amount of attached gingiva is generally considered to
be insufficient when stretching of the lip or cheek induces
movement of the free gingival margin.

To determine the width of the attached gingiva, the pocket is probed (A), and then the
probe is placed on the outer surface (B) while the lip (or cheek) is extended to demarcate
the mucogingival line. C, Another method to
demarcate the mucogingival line is pushing the lip (cheek) coronally .

Other methods used to determine the amount of attached
gingiva include pushing the adjacent mucosa coronally with a
dull instrument or painting the mucosa with Schiller's potassium
iodide solution, which stains keratin.

DEGREE OF GINGIVAL RECESSION
This measurement is taken with a periodontal probe from
the CEJ to the gingival crest, and it is drawn on the
patient's chart.

ALVEOLAR BONE LOSS
Alveolar bone levels are evaluated by clinical and radiographic
examination.
Probing is helpful for determining
(1 ) The height and contour of the facial and lingual bones
obscured on the radiograph by the roots
(2) The architecture of the interdental bone.

Transgingival Sounding
Transgingival probing, performed after the area is anesthetized,
is a more accurate method of evaluation and provides additional
information on bone architecture

PALPATION
Palpating the oral mucosa in the lateral and apical areas of
the tooth may help:
1) locate the origin of radiating pain that the patient cannot
localize.
2) Infection deep in the periodontal tissues
3) The early stages of a periodontal abscess may also be
detected by palpation.

SUPPURATION
Clinically, the presence of exudate 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 toward the
crown.

Purulent exudates expressed from a periodontal pocket by digital
pressure.

PERIODONTAL ABSCESS
A periodontal abscess is a localized accumulation of exudate
within the gingival wall of a periodontal pocket . Periodontal
abscesses may be acute or chronic.
The acute periodontal abscess appears as an ovoid elevation of
the gingiva along the lateral aspect of the root .
In most cases, exudate may be expressed from the gingival
margin with gentle digital pressure.

A- Facial view of acute periodontal abscess between the lower central incisors.
B, Lingual view of the same patient with a suppurating draining sinus.

Acute periodontal abscess in the wall of a
deep pocket in the lingual surface of lower
premolars
Acute periodontal abscess associated with a
deep periodontal pocket in palatal area of
first and second upper molars. Note how the
fibrotic character of the palatal tissue masks
the ty pical changes of the abscess.

NODULAR MASS AT THE ORIFICE OF A DRAINING SINUS.

Gingival abscess between upper lateral incisor and canine.

LABORATORY AIDS TO CLINICAL DIAGNOSIS
When unusual gingival or periodontal problems are
detected that cannot be explained by local causes, the
possibility of contributing systemic factors must be
explored.
Numerous laboratory tests aid in the diagnosis of systemic
diseases that may contribute to periodontal and oral
diseases will also be needed for the treatment decisions
when dealing with medically compromised patients.

DETERMINATION OF PROGNOSIS
Definitions
The prognosis is a prediction of the probable course, duration, and
outcome of a disease based on a general knowledge of the
pathogenesis of the disease and the presence of risk factors for
the disease.
It is established after the diagnosis is made and before the
treatment plan .

The prognosis is based on :
1) Specific information about the disease
2) The manner in which it can be treated
3) The clinician's previous experience with treatment
outcomes (successes and failures) .

Risk factors
prognosis
Deals with the likelihood that an individual
will develop a disease in a specified
period
Is the prediction of the course or outcome
of a disease and its response to treatment
Risk factors are those characteristics of an
individual that put the person at increased
risk for developing a disease
Prognostic factors are characteristics that
predict the outcome of disease
once the disease is present.
Prognosis is often confused with the term risk.

In some cases, risk factors and prognostic factors are the
same.
For example, patients with diabetes or patients who
smoke are more at risk for acquiring periodontal disease,
and once they have it, they generally have a worse
prognosis.

FACTORS FOR DETERMINATION OF PROGNOSIS

FACTORS TO CONSIDER WHEN DETERMINING A
PROGNOSIS
Overall Clinical Factors
Patient age
Disease severity
Plaque control
Patient compliance
Systemic and Environmental Factors
Smoking
Systemic disease or condition
Genetic factors
Stress DR SAHAR ABDELATIF ABDELRHMAN

Local Factors
Plaque and calculus
Subgingival restorations
Anatomic Factors
Short, tapered roots
Cervical enamel projections
Enamel pearls
Bifurcation ridges
Root concavities
Developmental grooves
Root proximity
Furcation involvement
Tooth mobility

Prosthetic and Restorative Factors
Abutment selection
Caries
Non vital teeth
Root resorption

TYPES OF PROGNOSIS
Prognosis classification schemes have been designed
based on studies evaluating tooth mortality
Good prognosis:
Control of etiologic factors and adequate periodontal
support ensure the tooth will be easy to maintain by the
patient and clinician.

Fair prognosis:
Approximately 25% attachment loss
And/or Class I furcation involvement (location and depth allow proper
maintenance with good patient compliance).
Poor prognosis:
50% attachment loss
Class II furcation involvement (location and depth make maintenance
possible but difficult).

Questionable prognosis:
>50% attachment loss
Poor crown-to-root ratio
Poor root form
Class II furcations (location and depth make access difficult)
Class III furcation involvements; >2+ mobility; root proximity.
Hopeless prognosis:
Inadequate attachment to maintain health, comfort, and function.

Kwok and Caton have proposed a scheme based on “the
probability of obtaining stability of the periodontal supporting
apparatus.
This scheme is based on the probability of disease progression
as related to local and systemic factors.

This scheme is as follows:
Favourable prognosis:
Comprehensive periodontal treatment and
maintenance will stabilize the status of the tooth.
Future loss of periodontal support is unlikely.

Questionable prognosis:
Local and/or systemic factors influencing the periodontal status
of the tooth may or may not be controllable.
If controlled, the periodontal status can be stabilized with
comprehensive periodontal treatment.
If not, future periodontal breakdown may occur.

Unfavorable prognosis:
Local and/or systemic factors influencing the periodontal status
cannot be controlled.
Comprehensive periodontal treatment and maintenance are
unlikely to prevent future periodontal breakdown.
Hopeless prognosis:
The tooth must be extracted.

OVERALL VERSUS INDIVIDUAL TOOTH PROGNOSIS
Prognosis can be divided into:
1) Overall prognosis
2) Individual tooth prognosis.
The overall prognosis answers the following questions:
• Should treatment be undertaken?
• Is treatment likely to succeed?
• When prosthetic replacements are needed, are the remaining
teeth able to support the added burden of the prosthesis?

The overall prognosis is concerned with the dentition as a whole.
Factors that may influence the overall prognosis include:
1) Patient age
2) Current severity of disease
3) Systemic factors
4) Smoking
5) The presence of plaque, calculus, and other local factors
6) Patient compliance
7) Prosthetic possibilities

The individual tooth prognosis is determined after the
overall prognosis and is affected by it.
Many of the factors listed under local factors and
prosthetic and restorative factors have a direct effect
on the prognosis for individual teeth, in addition to any
overall systemic or environmental factors that may be
present.

REVALUATION OF PROGNOSIS AFTER PHASE I THERAPY
A frank reduction in pocket depth and inflammation after phase I
therapy indicates a favourable response to treatment and may
suggest a better prognosis than previously assumed.
If the inflammatory changes present cannot be controlled or
reduced by phase I therapy, the overall prognosis may be
unfavourable.

TREATMENT PLAN
After the diagnosis and prognosis have been established, the
treatment is planned.
The plan should encompass short- and long-term goals.
The short-term goals are the elimination of all infectious and
inflammatory processes that cause periodontal and other oral
problems that may hinder the patient's general health.

The long-term goals are the reconstruction of a healthy
dentition that fulfils all functional and aesthetic
requirements.

The treatment plan is the blueprint for case management.
It includes all procedures required for the establishment and
maintenance of oral health and involves the following decisions:
• Need for emergency treatment (pain, acute infections).
• Teeth that will require removal.
• Periodontal pocket therapy techniques (surgical or nonsurgical).

Endodontic therapy.
• The need for occlusal correction, including orthodontic therapy.
• The use of implant therapy.
• The need for caries removal and the placement of temporary and
final restorations.
• Prosthetic replacements that may be needed and which teeth will be
abutments if a fixed prosthesis is used.
• Decisions regarding esthetic considerations in periodontal therapy.
• Sequence of therapy

PHASES OF PERIODONTAL THERAPY
Preliminary Phase
Treatment of emergencies:
• Dental or periapical
• Periodontal
• Other
Extraction of hopeless teeth and provisional replacement
if needed (may be postponed to a more convenient
time)

NONSURGICAL PHASE (PHASE I THERAPY)
Plaque control and patient education:
• Diet control (in patients with rampant caries)
• Removal of calculus and root planing
• Correction of restorative and prosthetic irritational
factors
•Excavation of caries and restoration (temporary or
final, depending on whether a definitive prognosis for
the tooth has been determined and the location of
caries)

• Antimicrobial therapy (local or systemic)
• Occlusal therapy
• Minor orthodontic movement
• Provisional splinting and prosthesis

Evaluation of Response to Nonsurgical Phase
Rechecking:
• Pocket depth and gingival inflammation
• Plaque and calculus, caries
Surgical Phase (Phase II Therapy)
• Periodontal surgical therapy, including placement of
implants
• Endodontic therapy

Restorative Phase (Phase III Therapy)
• Final restorations
• Fixed and removable prosthodontic appliances
• Evaluation of response to restorative procedures
• Periodontal examination

Maintenance Phase (Phase IV Therapy)
Periodic rechecking:
• Plaque and calculus
• Gingival condition (pockets, inflammation)
• Occlusion, tooth mobility
• Other pathologic changes

The sequence in which these phases of therapy are performed may vary to
some extent in response to the requirements of the case.
The preferred sequence, which covers the vast majority of cases, is:

EXPLAINING TREATMENT PLAN TO THE PATIENT
Be specific
Tell your patient, “You have gingivitis” or “You have
periodontitis,” then explain exactly what these conditions are.
Avoid vague statements.
Do not use statements such as, “You have trouble with your
gums” or “Something should be done about your gums.” Patients
may not understand the significance of such statements and may
disregard them.

Begin your discussion on a positive note.
Talk about the teeth that can be retained and the long-term service they can be
expected to render.
Do not begin your discussion with the statement, “The following teeth have to
be extracted

Present the entire treatment plan as a unit
Avoid creating the impression that treatment consists of separate
procedures, some or all of which may be selected by the patient

RATIONALE FOR PERIODONTAL TREATMENT

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