Case History And ClinicalDiagnosis in Periodontics        INDIAN DENTAL ACADEMY     Leader in Continuing Dental Education ...
Terminology   Case History: a planned professional conversation    which enables the patient to communicate his/her    sy...
Principles of Diagnosis   Specificity: the ability of a test or observation to    clearly differentiate one disease from ...
Name   Identification of the Patient   Builds a better communication rapport with    the patient   Inspires confidence ...
Age   To recognize age specific diseases       Juvenile Periodontitis       Pre Pubertal Periodontitis       Acute Her...
Sex   To Recognize sex specific diseases       Juvenile Periodontitis       Changes associated in Pregnancy            ...
Occupation   Certain Occupations are capable of    producing diseases – “Occupational    Hazards”       Factory workers ...
Address   Future contact with the patients for follow up    appointments   To recognize area specific diseases       Fl...
Chief Complaint   The presenting problem of the patient   Has to be recorded in the patients own words    in 1-2 sentenc...
History of the Present Illness   Elaboration of the Chief Complaint       In case of Pain           Mode of Onset      ...
   In case of Lesion              Bleeding Gums       When the lesion was            Time of onsent        first obser...
Medical History   Enables the monitoring of medical conditions and the evaluation of    underlying systemic conditions  ...
Leukemic Gingival Enlargement                                       ↓              ↑Cyclosporine induced GingivalEnglargme...
Dental History   Any past dental history –    Duration and nature of the    treatment   Orthodontic treatment –    Durat...
Family History   History of any    hereditary linked    problems       Diabetes       Hemophilia       Hypertension   ...
Personal History   Diet   Smoking / Tobacco use   Drug use   Brushing habits   Parafunctional Habits   Other habits ...
Diet   Whether mixed or vegetarian   Vegetarian diets – fibrous in nature, stimulate    saliva and have self cleansing a...
Smoking and Tobacco Use   Smoking is directly related    to the development of    periodontitis.   Decreased resistance ...
Bruxism   The clenching / grinding of the teeth when the    individual is not chewing or swallowing.   Can be Nocturnal ...
Clenching   “Centric Bruxism”   Repetitive prolonged forceful contact of the    teeth with no or extremely minimal    ma...
Lip/Cheek Biting   May cause excessive scarring of mucosal    surfaces and occasionally malpositioning of    the teeth in...
Tongue Thrusting   Persistent forceful wedging of the         Determination:    tongue against the teeth particularly   ...
Mouth Breathing   Gingival changes include:       Erythema       Edema       Enlargement       Diffuse surface to the...
Extra Oral General Examination   Build, height and weight of that patient are noted.   Jaw symmetry: any asymmetry is to...
www.indiandentalacademy.com
Intra Oral General Examination   Labial and Buccal Mucosa:       Palpate upper and lower lips for any thickening or swel...
   Floor of the Mouth:       Observe:           The opening of Wharton’s Duct           Salivary pad           Swelli...
Examination of the Gingiva   Color:       Normal healthy gingiva appears        coral pink or coral pink with        pig...
   Size:       Corresponds to the sum total of        cellular and intercellular and        vascular supply       Vascu...
   Consistency:     Normal gingiva is firm and resilient (except for the free margin), tightly      bound to the underly...
   Exudation:   Adequacy of Attached Gingiva:     The attached gingiva is continuous with the marginal gingiva and     ...
   Position of the Gingiva:       Refers to the level at which the gingival margin is        attached to the tooth.    ...
Gingival Recession   Progressive exposure of the    root surface resulting from    apical migration of junctional    epit...
   Classification by P.D. Miller:                   Classification by Sullivan and Atkins:       Class I - Marginal tis...
The Gingival Index   Developed by Loe H. and Silness J. in 1963.   Solely for the purpose of assess the severity of ging...
   Scoring criteria for the Gingival Index:     0 = Absence of inflammation – Normal Gingiva     1 = Mild Inflammation,...
The Simplified Oral Hygiene Index   Has two components:     Simplified Debris index     Simplified Calculus index   Mo...
   Debris Index:                       Calculus Index:       0 = No Debris                       0 = No Calculus     ...
   Calculation of Debris and Calculus Indices:       Debris or calculus index = Total score divided by        the number...
Periodontal Pockets   A Pathologically    deepened gingival    sulcus   If the depth of the      William’s Graduated Per...
Furcation Involvement   Extension of the periodontal    disease into the bifurcation              ←Furcation Probing    a...
Hard Tissue Examination   Teeth Missing: Long span edentulous areas have a    tendency towards mesial migration of teeth ...
Calculus    Consists of mineralized bacterial plaque    Supragingival calculus:        Visible in the oral cavity     ...
Supragingival Calculus on Molar         Supragingival Calculus on Lingual SurfacesExtensive Supra and Sub gingival Calculu...
Wasting Diseases   Wasting is defined as any gradual loss of    tooth substance characterized by the    formation of smoo...
   Abrasion       Loss of tooth substance induced by mechanical wear other than that        of mastication.       Cause...
Pathologic Migration   Refers to the tooth displacement that results    when the balance between the factors that    main...
Mobility   Grades of Mobility:       Grade I : Slightly more than        normal       Grade II : Moderately more       ...
Proximal Contacts   Slightly open contacts permits food impaction   The tightness of contacts should be checked by    me...
Rotation   Teeth are rotated       Mesially       Facially       Lingually or palatally   Favors plaque accumulation ...
Faulty Restorations   Overhanging margins of    dental restorations    contribute to the    development of periodontal   ...
Malalignment   Tooth malalignment predisposes to plaque    accumulation and inflammation in children    and predisposes t...
Occlusal Analysis   Overbite:      Seen most often in the anterior region      May cause impingement of the teeth on th...
Trauma from Occlusion   Primary Trauma from Occlusion:       Occurs if trauma from occlusion is the primary etiologic fa...
   Secondary Trauma from Occlusion:       Occurs when the adaptive capacity of the tissues        to withstand occlusal ...
Radiographs   Provide information    about the distribution    and severity of bone    destruction            www.indiand...
Investigations   Based on the systemic status, various tests    may be indicated.       Bleeding time determination    ...
Diagnosis   May be:       Acute or Chronic       Localized or Generalized   Inflammation of the gingiva with bleeding ...
Prognosis   The prediction of the duration, course and    termination of the disease and its response to    treatment   ...
Treatment Plan   Scheduled sequence of therapeutic measures used to cure or arrest the disease process   Preliminary Pha...
Thank Youwww.indiandentalacademy.com
Juvenile Periodontitis   Age Group: 15-19 years   Commonly seen in females   Distribution: 1st Molars and Incisors   L...
Juvenile Periodontitis       www.indiandentalacademy.com
Acute Herpetic Gingivostomatitis   Age Group: Infants and Children below 6yrs    of age   Diffuse erythematous shiny inv...
Acute Necrotizing Ulcerative Gingivitis   Seen in adults   Punched out crater like    depressions at the    crest of the...
Changes in the Gingiva Seen DuringPregnancy   Pregnancy accentuates the gingival response    to plaque and modifies the r...
Pre Pubertal Periodontitis   Age Group: Below 11 years of age   Patient becomes edentulous as there is rapid    destruct...
Pubertal Changes in the Gingiva   Exaggerated Response of the gingiva to local    irritants       Inflammation       En...
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Case history & diagnosis in periodontics /certified fixed orthodontic courses by Indian dental academy

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  • Mixed diet???
  • Smokers palate? Next slide Brushing habits clarify
  • Check defn. of bruxism
  • Palatal rugae?
  • Case history & diagnosis in periodontics /certified fixed orthodontic courses by Indian dental academy

    1. 1. Case History And ClinicalDiagnosis in Periodontics INDIAN DENTAL ACADEMY Leader in Continuing Dental Education www.indiandentalacademy.com
    2. 2. Terminology Case History: a planned professional conversation which enables the patient to communicate his/her symptoms and fears to the clinician and recorded in the patients own words as to obtain an insight into the nature of the patient’s illness and his/her attitude to them. Diagnosis: The correct determination, discriminative estimation and logical appraisal of the conditions found during examination as evidenced by signs and symptoms of health and disease. www.indiandentalacademy.com
    3. 3. Principles of Diagnosis Specificity: the ability of a test or observation to clearly differentiate one disease from another Sensitivity: the ability of a test or observation to detect the disease whenever it is present Predictive Value: the probability that the test result (i.e. the proportion of true positive results and true negative results combined) agrees with the disease status www.indiandentalacademy.com
    4. 4. Name Identification of the Patient Builds a better communication rapport with the patient Inspires confidence of the patient in the clinician www.indiandentalacademy.com
    5. 5. Age To recognize age specific diseases  Juvenile Periodontitis  Pre Pubertal Periodontitis  Acute Herpetic Gingivostomatitis  Acute Necrotizing Ulcerative Gingivitis  Pubertal Gingival Changes www.indiandentalacademy.com
    6. 6. Sex To Recognize sex specific diseases  Juvenile Periodontitis  Changes associated in Pregnancy www.indiandentalacademy.com
    7. 7. Occupation Certain Occupations are capable of producing diseases – “Occupational Hazards”  Factory workers in metal workshops show gingival pigmentations  Lung Cancer in Beedi Workers  Silicosis in Watch Worker  Abrasion of anterior teeth in carpenters / tailors www.indiandentalacademy.com
    8. 8. Address Future contact with the patients for follow up appointments To recognize area specific diseases  Fluorosis www.indiandentalacademy.com
    9. 9. Chief Complaint The presenting problem of the patient Has to be recorded in the patients own words in 1-2 sentences Obtained by asking the patient to describe the problem for which help is being sought or reason for visit www.indiandentalacademy.com
    10. 10. History of the Present Illness Elaboration of the Chief Complaint  In case of Pain  Mode of Onset  Duration  Type of pain  Radiation or localization of the pain  Severity  Aggravating and relieving factors  Whether the patient has taken any medication or has consulted a doctor www.indiandentalacademy.com
    11. 11.  In case of Lesion  Bleeding Gums  When the lesion was  Time of onsent first observed  Spontaneous/ on  Mode of development brushing/ while eating  Symptoms  Associated with Menstrual Cycle or  Previous Treatment other specific factors  Duration of bleeding  Manner of stopping www.indiandentalacademy.com
    12. 12. Medical History Enables the monitoring of medical conditions and the evaluation of underlying systemic conditions Provides a basis for determining whether the dental treatment might affect the systemic health of the patient Provides an initial starting point for assessing the possible influence of the patient’s systemic health on the patient’s oral health and/or dental treatment Importance to be explained to patient – patients often omit information that they cannot relate to their dental problem. Should include:  If under the care of any physician at the present time.  Recent / past hospitalizations or operations to rule out any infections, anesthetic and hemorrhagic complications.  Any medication being taken at the present time (stress on anticoagulants and steroids)  Abnormal bleeding tendencies.  History of allergies  Information regarding the onset of puberty in females, menopause, menstrual disorders, pregnancies www.indiandentalacademy.com
    13. 13. Leukemic Gingival Enlargement ↓ ↑Cyclosporine induced GingivalEnglargment www.indiandentalacademy.com
    14. 14. Dental History Any past dental history – Duration and nature of the treatment Orthodontic treatment – Duration and termination of the treatment Pain in the teeth or gums History of previous Gingival Enlargement Associated periodontal problems – with Orthodontic Applicance Type or treatment (Surgical/Non Surgical) www.indiandentalacademy.com
    15. 15. Family History History of any hereditary linked problems  Diabetes  Hemophilia  Hypertension Diabetes – Gingival Enlargement www.indiandentalacademy.com
    16. 16. Personal History Diet Smoking / Tobacco use Drug use Brushing habits Parafunctional Habits Other habits www.indiandentalacademy.com
    17. 17. Diet Whether mixed or vegetarian Vegetarian diets – fibrous in nature, stimulate saliva and have self cleansing action Sticky food – increased retention of plaque. www.indiandentalacademy.com
    18. 18. Smoking and Tobacco Use Smoking is directly related to the development of periodontitis. Decreased resistance of gingiva due to local irritants and subsequent increase in plaque formation. Smokers Palate – nicotinic stomatitis characterized by prominent mucous glands and inflammation around the orifices. Diffuse erythema with cobblestone appearance. Tobacco Stains Smokers Melanosis – brown flat irregular lesions or map like configuration. www.indiandentalacademy.com
    19. 19. Bruxism The clenching / grinding of the teeth when the individual is not chewing or swallowing. Can be Nocturnal or Diurnal Can occur as a rhythmic side to side movement or through a sustained clench. May lead to:  Tooth wear  Fractures  Muscle hypertrophy  Masticatory myalgia  Headaches www.indiandentalacademy.com
    20. 20. Clenching “Centric Bruxism” Repetitive prolonged forceful contact of the teeth with no or extremely minimal mandibular movements. May result in:  Isometric muscle changes  Pathologic changes of the periodontal supporting structures  Secondary changes in the TMJ www.indiandentalacademy.com
    21. 21. Lip/Cheek Biting May cause excessive scarring of mucosal surfaces and occasionally malpositioning of the teeth involved Localized malpositioning may in turn result in functional occlusal interferences and associated occlusal traumatization and also keratinization www.indiandentalacademy.com
    22. 22. Tongue Thrusting Persistent forceful wedging of the  Determination: tongue against the teeth particularly  Hold the lips apart and as the patient in the anterior region to swallow. Causes excessive lateral pressure  Check palatal rugae that may be traumatic to the periodontium. Spreading and tilting of the anterior teeth with anterior and posterior open bites. Tooth mobility Accumulation of food debris at the gingival margin In accentuated tongue thrusters there is a scalloping of the tongue – “Heavy Tongue” www.indiandentalacademy.com
    23. 23. Mouth Breathing Gingival changes include:  Erythema  Edema  Enlargement  Diffuse surface to the exposed areas. Tests to diagnose mouth breathing:  Butterfly test  Water in the Mouth Test  Double Mirror Test www.indiandentalacademy.com
    24. 24. Extra Oral General Examination Build, height and weight of that patient are noted. Jaw symmetry: any asymmetry is to be detected as in the case of facial swelling. Lips:  Note lip color, texture, any surface abnormalities as well as angular or vertical fissures, lip pits, cold sores, ulcers, scabs, nodules, keratotic plaques and scares.  Palpate upper and lower lips for thickening and swelling  Note Lip seal and competancy of the lips TMJ: Note any deviation, clicking sounds while opening and closing indicative of a TMJ disorder. Lymph Nodes:  Inflammed nodes are tender, palpable and fairly mobile  Seen in ANUG, Acute Periodontal Abscesses. www.indiandentalacademy.com
    25. 25. www.indiandentalacademy.com
    26. 26. Intra Oral General Examination Labial and Buccal Mucosa:  Palpate upper and lower lips for any thickening or swelling.  Note orifices of minor salivary glands and the presence of fordyces granules. Tongue:  Inspect dorsum for:  Swelling and ulcers  Coating  Variations in color and texture  Inspect margins for:  Distribution of papillae  Crenations and fasiculations  Depapillated areas  Fissures, ulcers and keratotic areas.  Inspect ventral aspect for:  Varicosities  Tight frenal attachments  Stones in Wharton’s Duct  Ulcers, swellings and red or white patches  Observe base of the tongue and vallate papillae www.indiandentalacademy.com
    27. 27.  Floor of the Mouth:  Observe:  The opening of Wharton’s Duct  Salivary pad  Swellings, ulcers or red and white patches Pharynx and Tonsils:  Palpate the tonsils for discharge or tenderness.  Note restriction of the oropharynx and airway  Examine the faucial pillars for:  Bilateral symmetry  Nodules  Red and white patches  Lymphoid aggregates  Deformities www.indiandentalacademy.com
    28. 28. Examination of the Gingiva Color:  Normal healthy gingiva appears coral pink or coral pink with pigmentation  Factors affecting color are:  Pigmentation  Vascularity  Keratinization  Gingiva appears:  White in case of smokers and trauma  Pale red in mild inflammation  Bright red in acute inflammation  Magenta in chronic inflammation  Color changes in relation to marginal, interdental and attached gingiva are noted. In case all three components are involved, then it is Normal Gingiva called “Diffuse” www.indiandentalacademy.com
    29. 29.  Size:  Corresponds to the sum total of cellular and intercellular and vascular supply  Vascular component is increased in case of inflammation.  Cellular components are increased in case of hyperplasia  Enlargement may be Chronic inflammatory “Inflammatory” or “Fibrotic” gingival enlargement Contour:  Normal gingiva has scalloped contours with knife edge margins  This configuration is lost when there is spacing or recession  In case of inflammation, scalloping is exaggerated with rounded margins. Marginal Gingivitis and Irregular Gingival Contour www.indiandentalacademy.com
    30. 30.  Consistency:  Normal gingiva is firm and resilient (except for the free margin), tightly bound to the underlying bone  Factors determining consistency:  Collagenous nature of the lamina propria  Attachment to the mucoperiosteum  Gingival Fibers  Chronic gingivitis: soggy puffiness that pits on pressure  Acute gingivitis: reffine puffiness and softency  Fibrosis and long standing inflammation: Firm and leathery consistancy Surface Texture:  Normal gingiva shows presence of stippling (alternating rounded protuberances and depressions in the gingival surface)  Stippling is a form of adaptive specialization or reinforcement for function  Seen in the attached and central portion of the interdental gingiva  Stippling is absent in infants and in old age and on the lingual surfaces  Stippling is lost in gingival infections  Stippling increases on stimluation of the gingiva  Viewed by drying the gingiva. www.indiandentalacademy.com
    31. 31.  Exudation: Adequacy of Attached Gingiva:  The attached gingiva is continuous with the marginal gingiva and tightly bound to the underlying bone.  Prevents to an extent, pocket formation and resists occlusal forces.  It is maximum in the incisor region and minimumin the premolar region  Tension Test: Ask the patient to bite, pull the lips outward and side-wards. In case of inadequacy, marginal gingiva moves downwards due to lack of adequate attachment. Frenal Attachment:  The Frenum is a fold of mucous membrane with enclosed muscle fibers that attached the lips and cheeks to the alveolar mucosa/gingiva and underlying periosteum  Types of frenal attachments:  Mucosal  Gingival  Papillary  Papillary Penetrating www.indiandentalacademy.com
    32. 32.  Position of the Gingiva:  Refers to the level at which the gingival margin is attached to the tooth.  It is at the level of the Cemento-Enamel Junction (CEJ) or above.  In case of recession, it is present in an apical position  In case of inflammation, it is present in a coronal position www.indiandentalacademy.com
    33. 33. Gingival Recession Progressive exposure of the root surface resulting from apical migration of junctional epithelium Etiology:  Improper and traumatic tooth brushing  Abnormal frenal attachment  Gingival Inflammation  Tooth malposition  Friction from soft tissues Recession can be localized or generalized, diffuse or hidden www.indiandentalacademy.com
    34. 34.  Classification by P.D. Miller:  Classification by Sullivan and Atkins:  Class I - Marginal tissue recession  Shallow Narrow Recession that does not extend to the mucogingival junction  Shallow Wide Recession  Class II - Marginal tissue recession that extends beyond the mucogingival junction  Deep Narrow Recession  Class III – Marginal tissue recession that extends beyond the  Deep Wide Recession mucogingival junction, there is bone loss and soft tissue loss interdentally or malposed tooth  Class IV – Marginal tissue recession that extends to or beyond the mucogingival junction with severe bone and soft tissue loss interdentally and/or severe malpositioning of teeth www.indiandentalacademy.com
    35. 35. The Gingival Index Developed by Loe H. and Silness J. in 1963. Solely for the purpose of assess the severity of gingivitis and its location in four possible areas of teeth. Method:  The severity of gingivitis is scored on all surfaces of all teeth. The tissues surrounding each tooth are divided into 4 gingival scoring units:  Distal facial papilla  Facial margin  Mesial facial papilla  Entire lingual gingival margin  A blunt instrument (periodontal probe) is used to asses the bleeding potential of the tissues. www.indiandentalacademy.com
    36. 36.  Scoring criteria for the Gingival Index:  0 = Absence of inflammation – Normal Gingiva  1 = Mild Inflammation, slight change in color, slight edema, No Bleeding on probing  2 = Moderate inflammation, moderate glazing, redness, edema and hypertrophy. Bleeding on Probing  3 = Severe inflammation, marked redness, ulceration, spontaneous bleeding Calculation of the Index:  The scores around each tooth are totalled and divided by 4 – the gingival index for the individual tooth is obtained.  Totalling al of the scores per tooth and dividing by the number of teeth examined provides the gingival index score per person Inference: Score of 0.1 - 1.0 = Mild Gingivitis Score of 1.1 - 2.0 = Moderate Gingivitis Score of 2.1 - 3.0 = Severe Gingivitis www.indiandentalacademy.com
    37. 37. The Simplified Oral Hygiene Index Has two components:  Simplified Debris index  Simplified Calculus index Mouth is divided in to 6 sextants with only indexed teeth being examined in each sextant:  16,11,26,36,31,4  In case 16 is absent 17 or 15 is examined (Buccal)  In case 11 is absent 21 is examined (Buccal)  In case 26 is absent 27 or 25 is examined (Buccal)  In case 36 is absent 37 or 35 is examined (Lingual)  In case 31 is absent 41 is examined (Buccal)  In case 46 is absent 47 pr 45 is examined (Lingual)  In case there are less that 2 functional teeth in a sextant, the sextant is not considered. www.indiandentalacademy.com
    38. 38.  Debris Index:  Calculus Index:  0 = No Debris  0 = No Calculus  1 = Debris present on  1 = Supragingival less that ⅓ of the tooth calculus involving less surface but less than ⅔ than ⅓ of the tooth and/or the presence of surface. extrinsic stains.  2 = Supragingival  2 = Debris present on calculus present upto the more that ⅓ but less than middle third of the tooth ⅔ of the tooth surface. surface and/or flecks of  Debris present on ⅔ or subgingival calculus. more of the tooth surface.  3 = Supragival calculus involving more than ⅔ of the tooth surface and/or a continuous band of subgingival calculus www.indiandentalacademy.com
    39. 39.  Calculation of Debris and Calculus Indices:  Debris or calculus index = Total score divided by the number of teeth examined Calculation of Simplified Oral Hygiene Index:  OHI-S = CI(S) + DI(S) Inference:  0 – 1.2 = Good Oral Hygiene  1.3 – 3.0 = Fair Oral Hygiene  3.0 – 6.0 = Poor Oral Hygiene www.indiandentalacademy.com
    40. 40. Periodontal Pockets A Pathologically deepened gingival sulcus If the depth of the William’s Graduated Periodontal Probe sulcus is greater than 3mm it is considered a ← Probe Revealing Extent of pocket Periodontal Measured with Pocket William’s Graduated Periodontal Probe. www.indiandentalacademy.com
    41. 41. Furcation Involvement Extension of the periodontal disease into the bifurcation ←Furcation Probing and trifurcation area of multi- rooted teeth. Human Skull Determined using Naber’s Demonstrating Probe Furcation Classification: Involvement ↓  Grade I : Incipient or early lesion  Grade II : Cul-de-sac lesion  Grade III : Through and through involvement, complete inter-radicular bone loss  Grade IV : Through and Through Involvement with exposure of the furcation area clinically www.indiandentalacademy.com
    42. 42. Hard Tissue Examination Teeth Missing: Long span edentulous areas have a tendency towards mesial migration of teeth distal to the space. In such cases the distal cusp of the migrated tooth acts as a plunger cusp, thereby forcefully lodging food between the extruded opposite tooth and its adjacent tooth. Thereby leading to food impaction, gingival inflammation and bone loss Stains or discolorations:  Pigmented deposits on the tooth surface.  Primarily esthetic  Detected visually  Can be easily removed. www.indiandentalacademy.com
    43. 43. Calculus  Consists of mineralized bacterial plaque  Supragingival calculus:  Visible in the oral cavity  White or whitish yellow in color  Hard clay like consistancy  Commonly seen on the lingual surface of mandibular anteriors and buccal surface of maxillary molars  Subgingival calculus:  Hard and dense  Dark brown or greenish black in color.  Firmly attached to the tooth surface.  Detected by tactile perception with an explorer (No. 17 or 3A)  Warm air may be used to deflect the gingiva and aid in visualization of calculus www.indiandentalacademy.com
    44. 44. Supragingival Calculus on Molar Supragingival Calculus on Lingual SurfacesExtensive Supra and Sub gingival Calculus Subgingival Calculus on Extracted Tooth www.indiandentalacademy.com
    45. 45. Wasting Diseases 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 the loss. The forms of wasting diseases are:  Abrasion  Attrition  Erosion www.indiandentalacademy.com
    46. 46.  Abrasion  Loss of tooth substance induced by mechanical wear other than that of mastication.  Causes:  Tooth brushing with an abrasive dentrifice  Action of clasps on abutment teeth  Results in saucer shaped or wedge shaped indentations with smooth shiny surface  Continued exposure to the abrasive agent, combined with decalcification of the enamel by locally forming acids may result in loss of enamel followed by loss of dentin Attrition  Occlusal wear resulting from functional contacts with opposing teeth  Increases with Increase in age Erosion  Cuneiform defect  A sharply defined wedge shaped depression in the cervical area of the 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  Causes: decalcification by acid beverages or citrus fruits along with the combined effect of acid salivary secretion and friction www.indiandentalacademy.com
    47. 47. Pathologic Migration Refers to the tooth displacement that results when the balance between the factors that maintain physiologic tooth position is disturbed by periodontal disease Causes:  Trauma from Occlusion  Pressure from the tongue  Pressure from the granulation tissue of periodontal pockets www.indiandentalacademy.com
    48. 48. Mobility Grades of Mobility:  Grade I : Slightly more than normal  Grade II : Moderately more than normal  Grade III : Severe mobility facio-lingually and /or mesiodistally combined with vertical displacement Causes:  Loss of tooth support  Trauma from occlusion  Endo-perio lesions  Trauma  Pregnancy Determining Mobility www.indiandentalacademy.com
    49. 49. Proximal Contacts Slightly open contacts permits food impaction The tightness of contacts should be checked by means of clinical observation and with dental floss Abnormal contact relationships may also initiate occlusal changes such as:  Shift in the median line between the central incisors  Labio-version of the maxillary canine  Buccal or lingual displacement of the posterior teeth  And uneven relationship of the marginal ridges www.indiandentalacademy.com
    50. 50. Rotation Teeth are rotated  Mesially  Facially  Lingually or palatally Favors plaque accumulation www.indiandentalacademy.com
    51. 51. Faulty Restorations Overhanging margins of dental restorations contribute to the development of periodontal disease Location of the gingival margin of the restoration is directly related to the health status of the adjacent periodontal tissues Roughness in the Inflammed Papilla due to subgingival areas is Overhanging Restoration considered www.indiandentalacademy.com
    52. 52. Malalignment Tooth malalignment predisposes to plaque accumulation and inflammation in children and predisposes to clinical attachment loss in adults, especially when associated with poor oral hygiene Open contacts have been associated with increased loss of alveolar bone, most probably through food impaction www.indiandentalacademy.com
    53. 53. Occlusal Analysis Overbite:  Seen most often in the anterior region  May cause impingement of the teeth on the gingiva and food impaction followed by gingival inflammation, enlargement and pocket formation Overjet: an increase in the horizontal distance between the maxillary and mandibular anterior teeh Open Bite:  Condition occurs most often in the anterior region, although posterior openbites are occasionally seen  Reduced means of cleansing by the passage of food may lead to accumulation of debris, calculus formation and extrusion of teeth Cross Bite:  Overlap of the maxillary teeth by the mandibular teeth  May be bilateral of unilateral  May affect only a pair of antagonists  Causes trauma from occlusion, food impaction, spreading of mandibular teeth, associated gingival and periodontal disturbances. Plunger Cusps:  Cusps that tend to forcibly wedge food into the interproximal embrasures  Leads to food impaction and periodontal disease www.indiandentalacademy.com
    54. 54. Trauma from Occlusion Primary Trauma from Occlusion:  Occurs if trauma from occlusion is the primary etiologic factor in periodontal destruction  Causes:  High Fillings  Insertion of a prosthetic replacement that creates excessive forces on the abutment and antagonist teeth  Drifting movement and extrusion of teeth into edentulous spaces  Orthodontic movements  Fremitus Test:  Wet the ungloved finger and place it partially on the gingiva and partly on the teeth. Ask the patient to bite repeatedly.  If vibrations are felt it indicated trauma from occlusion.  Other factors that indicate trauma from occlusion:  Excessive mobility of teeth  Radiographically:  Widened PDL space  Vertical or angular bone loss  Infra-bony pockets  Pathological Migrations www.indiandentalacademy.com
    55. 55.  Secondary Trauma from Occlusion:  Occurs when the adaptive capacity of the tissues to withstand occlusal forces is impaired by bone loss resulting from marginal inflammation www.indiandentalacademy.com
    56. 56. Radiographs Provide information about the distribution and severity of bone destruction www.indiandentalacademy.com
    57. 57. Investigations Based on the systemic status, various tests may be indicated.  Bleeding time determination  Clotting time determination  Prothrombin Time estimation  Biopsies  Nutritional Status Evaluation  Hemogram www.indiandentalacademy.com
    58. 58. Diagnosis May be:  Acute or Chronic  Localized or Generalized Inflammation of the gingiva with bleeding on probing may indicate Gingivitis Presence of periodontal pockets, furcation involvement, recession may indicate Periodontitis www.indiandentalacademy.com
    59. 59. Prognosis The prediction of the duration, course and termination of the disease and its response to treatment Divided into:  Overall prognosis  Individual prognosis Further classified as:  Excellent  Good  Fair  Poor  Questionable  Hopeless www.indiandentalacademy.com
    60. 60. Treatment Plan Scheduled sequence of therapeutic measures used to cure or arrest the disease process Preliminary Phase:  Treatment of emergencies Phase I : Etiotrophic Phase  Education and motivation of the patient  Oral Prophylaxis  Minor Orthodontic Tooth Movement  Temporary Restorations Phase II : Surgical Phase  Periodontal Surgery  Root Canal Therapy Phase III : Restorative Phase  Final Restorations  Prosthetic Therapy  Fixed Orthodontic Therapy Phase IV : Maintainance Phase  Periodic Recall  Supportive Periodontal Therapy www.indiandentalacademy.com
    61. 61. Thank Youwww.indiandentalacademy.com
    62. 62. Juvenile Periodontitis Age Group: 15-19 years Commonly seen in females Distribution: 1st Molars and Incisors Lack of clinical inflammation with presence of deep periodontal pockets Distolabial migration of Maxillary Incisors and Molars www.indiandentalacademy.com
    63. 63. Juvenile Periodontitis www.indiandentalacademy.com
    64. 64. Acute Herpetic Gingivostomatitis Age Group: Infants and Children below 6yrs of age Diffuse erythematous shiny involvement of gingiva and oral mucosa Presence of vesicles www.indiandentalacademy.com
    65. 65. Acute Necrotizing Ulcerative Gingivitis Seen in adults Punched out crater like depressions at the crest of the interdental papilla, may extend up to the marginal gingiva www.indiandentalacademy.com
    66. 66. Changes in the Gingiva Seen DuringPregnancy Pregnancy accentuates the gingival response to plaque and modifies the resultant clinical picture  Bleeding  Inflammation  Bright red to Bluish discoloration  Raspberry like appearance of the interdental and marginal gingiva  Pregnancy Tumors: tumor like discrete masses. www.indiandentalacademy.com
    67. 67. Pre Pubertal Periodontitis Age Group: Below 11 years of age Patient becomes edentulous as there is rapid destruction of periodontium leading to loss of teeth Associated with Papillon Lefevre Syndrome, Downs Syndrome, Neutropenia. www.indiandentalacademy.com
    68. 68. Pubertal Changes in the Gingiva Exaggerated Response of the gingiva to local irritants  Inflammation  Enlargement  Bluish-red discoloration  Edema www.indiandentalacademy.com

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