2. INTRODUCTION
Proper diagnosis is essential to intelligent treatment.
In current practice of periodontics it is primarily derived from
information obtained from the patient’s medical and dental
histories combined with findings from a through oral
examination.
Listing of the possible diagnosis of a patient’s condition
ranked from most likely to least likely.
Important- because it provides the clinician with other
diagnostic options if the initial diagnosis subsequently proves
to be wrong.
DIFFERENTIAL DIAGNOSIS
3. DEFINITION
It the art of chronological organisation and critical evaluation
of the information obtained of the patients history , lab
investigations , clinical examinations so as to identify the
disease type and etiology.
4. CURRENT CLASSIFICATION SYSTEM-
what are possible periodontal diagnosis
Plaque induced periodontal disease have traditionally been
divided into three categories-
HEALTH
GINGIVITIS
PERIODONTITIS
5. HEALTH- Absence of plaque induced periodontal disease
PLAQUE INDUCED GINGIVITIS- Presence of gingival
inflammation without loss of connective attachment
PLAQUE INDUCED PERIODONTITIS- Presence of
gingival inflammation at sites where there has been apical
migration of the epithelial attachment onto the root surfaces
accompanied by loss of connective tissue and alveolar bone.
6. PARTIAL LIST OF POSSIBLE DIAGNOSIS FOR
GINGIVAL DISEASE 1999 CLASSIFICATION
DENTAL PLAQUE INDUCED GINGIVAL DISEASE
plaque-induced gingivitis without local contributing factor
plaque-induced gingivitis with local contributing factor
NUG
puberty associated gingivitis
pregnancy associated gingivitis
Diabetes mellitus associated gingivitis
Leukemia-associated gingivitis
Drug-influenced gingival enlargement
Ascorbic-acid deficiency gingivitis
8. Gingival manifestation of systemic condition
Lichen planus
Mucous membrane pemphigoid
Pemphigus vulgaris
Erythema multiforme
Lupus erythematossus
Wegner granulomatosis
Psoriasis
Allergic reactions of gingiva to
Restorative material
Mouthrinses
Traumatic lesion of gingiva
Chemical injury
Physical injury
Thermal injury
9. Partial list of possible diagnoses for destructive types of
periodontal disease (1999 classification).
Chronic periodontitis(localized/generalized)
Localized form: < 30% of sites are involved
Generalized form: >30% of sites are involved
Slight: 1to 2 mm of clinical attachment loss
Moderate : 3 to 4 mm of clinical attachment loss
Severe : > 5 mm of clinical attachment loss.
Aggressive periodontitis
Periodontitis as manifestation of systemic disease
1.Hematologic disorder
2.Genetic disorders
Down syndrome
Glycogen syndrome
10. Chronic periodontitis
associated with poor oral
hygiene in a medically
healthy person.
Inflammation, gingival
recession and attachment loss
Generalized aggressive
periodontitis in
medically healthy patient
14. First visit
OVERALL APPRAISAL OF PATIENT
In the very first meeting only clinician come to know about
patient’s mental and emotional status, attitude and
physiologic age.
Age-
Prepubertal periodontitis- < 11 years
NUP- 15 – 35 years
Aggressive periodontitis – 20-35 years
Juvenile periodontitis- 11- 19 years
15. MEDICAL HISTORY
Mostly obtained in first visit
Importance of medical history should be explained to patients
as they usually omit information due to lack of awareness.
So patient should be made aware of – role of systemic disease
and condition in periodontal conditions.
A complete history of hospitalization and surgery should be
provided.
Any history of allergy or adverse drug reaction should be
provided.
Any other medical problems
Abnormal bleeding tendencies
patient’s family medical history
16. DENTAL HISTORY
A list of dental visits should be supplied, including frequency,
date of most recent visit, oral prophylaxis by dentist including
frequency and date of most recent cleaning.
Patient’s oral hygiene regimen should be noted, including
tooth brushing frequency, method, type of tooth brush.
Pain in tooth or gums
Bleeding from gums
Halitosis
Patient’s general dental habbit such as clenching and grinding
habit.
Any sort of previous periodontal problems.
17. Intraoral radiographic survey
Radiographic survey consist of 14 intraoral films and 4
posterior bitewing films.
Bitewing radiographs – height of alveolar crest .
18. Periapical radiographs – crown to
root ratio, PDL space, periapical
abnormality.
oSubstraction radiography –
change in bone density.
20. Casts:
Indicate position of gingival margin , inclination of the teeth,
proximal contact relationships, food impaction areas.
Visual aid in discussion with patient.
22. Second visit
Oral hygeine :
Cleanliness of oral cavity is appraised in terms of extent of
accumulated food debris , plaque, materia alba, and tooth
surface stains.
Oral hygeine status (John c. Green, Jack Vermillion)
determined with the help of OHI-S
good- 0.1 - 1.3
fair – 1.3 – 3.0
poor – 3.0 – 6.0
23. Foul / offensive odor emanating from oral cavity
Causes: - pathologic
- non pathologic
systemic: ear-nose-throat, pulmonary causes, GIT causes ,
drugs.
Compound responsible – volatile sulfur compound.
Microbiology involved in VSC production – T.denticoli,
P.intermedia, P. gingivalis , F. Nucleatum , H. Influenza
Diagnosis: organoleptic measurements , oropharyngeal examination
, gas chromatography.
24. Lymph node examination
Head and neck lymph nodes should be examined .
Nodes enlarged in – primary herpetic gingivostomatitis, NUG,
acute periodontal abscess etc.
25. Frenum attachment
Frenum is a fold of mucous membrane usually
with enclosed muscle fibres that attaches lips
and cheek to alveolar mucosa/ gingiva and
underlying periosteum.
CLASSIFICATION
Merco et al 1974
( depending on the attachment fibres)
mucosal
gingival
papillary
papilla penetrating
26. Examination of periodontium
Gingival status
Colour
normal – coral pink
Chronic gingivitis- red, reddish blue,
Acute gingivitis( ANUG, HIV, herpetic gingivostomatitis,
chemical irritation) – brightish red erythema, shiny slate grey,
dull whitish grey.
Bismuth , arsenic , mercury pigmentation- black line
following gingival margin countour.
Lead pigmentation – deep blue linear pigmentation
Silver pigmentation – violet marginal line.
27. Contour
Normal – scalloped ,knife edge
Chronic gingivitis – rolled , rounded marginal gingiva
flat , blunt interdental papilla.
ANUG - punched out crater like depression.
Chronic desquamative gingivitis – irregularly shaped
denuded appearance of gingiva .
Stillman’s cleft- apostrophe shaped indentations
extending from gingival margin for varying distance on
the facial surfaces.
McCalls festoons – rolled , thickened band of gingiva
usually seen adjacent to cuspid when recession
approaches mucogingival junction .
31. Consistency
Normal – firm and resilient
Chronic gingivitis- soggy puffiness that pits on pressure
- marked softness and friability, pinpoint
surface area of redness and desquamation.
- firm and leathery
Acute gingivitis – diffuse puffiness and softening
- vesicle formation
- sloughing with greyish flake like particles of
debris.
32. Surface texture
Normal – orange peel appearance
Form of adaptive specialization for function
Papillary layer of connective tissue projects into the elevations covered by
stratified squamous epithelium.
Stippling best view by drying of gingiva.
Loss of stippling – early sign of gingivitis
33. Position
Refers to the level at which the gingival margin is attached to
the tooth.
Actual position : it is the level of epithelial attachment on
tooth at CEJ.
Apparent position : level of crest of gingival margin.
Recession: exposure of root surface by apical shift in position
of gingiva .
34. Bleeding on probing
Earliest sign of gingival inflammation .
Results from increased vascularity , thinning and degeneration
of the epithelium and the proximity of engorged blood vessels
to the inner surface.
Causes of bleeding:
- chronic bleeding
- acute bleeding
- systemic factors .eg vascular abnormality , platelet disorder ,
coagulation defects , malignancy, drugs,
hypoprothrombenemia.
38. Width of attached gingiva
It is the distance between the mucogingival junction and the
projection on the external surface of the bottom of the sulcus.
Test done to determine width of attach gingiva:
1. measurement approach
2. Schillers potassium iodide solution
3. Roll test
39. A PERIODONTAL POCKET is defined as a pathologically
deepened gingival sulcus
Pocket Probing
The probe should be inserted parallel to the vertical axis of tooth
and walked circumferentially around each surface of the tooth
to detect the areas of deepest penetration
40. Level of attachment versus pocket depth
Pocket depth – distance between base of pocket and gingival
margin
Level of attachment – distance between base of pocket and a
fixed point on crown such as CEJ.
41. Determining level of attachment
When gingival margin is located on anatomical crown level
of attachment determined by subtracting from PD the
distance from GM to CEJ.
When gingival margin coincide with CEJ the loss of
attachment equals PD.
When GM located apical to CEJ , loss of attachment is
greater than PD and thus distance between CEJ and GM
should be added to PD.
42. Alveolar bone loss
Evaluated by clinical and radiographic examination
Probing helpful for determining
- height and contour of facial and lingual bones obscured on
radiograph by dense root
- architecture of the interdental bone
Transgingival probing is a more accurate technique
greenstein et al 1981
43. Recession
Apical shift of gingival margin to a position apical to CEJ
with exposure of root surface to oral cavity.
Factors responsible for recession – inflammatory
- anatomical factors
- iatrogenic factors
classification :
1. Sullivan and Atkins – shallow narrow
- shallow wide
- deep narrow
- deep wide .
44.
45. Millers classification
class I- marginal tissue recession that does not extent to the
mucogingival junction. There is no loss of bone or soft
tissue in the interdental area.
class II- marginal tissue recession that extent to or beyond the
mucogingival junction. There is no loss of bone or soft
tissue in the interdental area.
.
46. class III- marginal tissue recession that extent to or beyond the
mucogingival junction, in addition there is bone or soft
tissue loss interdentally or malpositioning of the tooth.
class IV- marginal tissue recession that extent to or beyond the
mucogingival junction, with severe bone loss & soft tissue
loss interdentally or severe malpositioning
47. Examination of teeth
Wasting disease of teeth
1. Attrition : occlusal wear resulting from
functional contact with opposing teeth .
2. Abrasion : loss of tooth substance induced by
mechanical wear .that of mastication
48. Erosion : loss of tooth substance by a chemical process that does
not involve bacterial action .
4. Abfraction : results from occlusal loading surfaces causing
tooth flexure and mechanical microfractures and tooth
substance loss in the cervical area.
49. Tooth mobility
All teeth have slight degree of physiologic mobility which is
greatest in the morning ant progressively decreases.
Leary et al 1969
Mobility checked as tooth is held firmly between handles of 2
mettalic instrument and an effort is made to move in all directions.
Tooth mobility occur in following two stages
1. Initial or intrasocket stage the tooth moves within the
confines of pdl, this is associate with viscoelastic
distortion of pdl and redistribution of periodontal fluid.
This initial movement occurs with force of about
100gm and is about 0.05-0.1mm
Muhlemann et all 1960
50. 2. The secondary stage occur gradually and entails elastic
deformation of alveolar bone in response to increase
horizontal forces.
( Leary et al 1965)
When force applied on crown is 500gm then displacement
is100-200 micro m for incisors, 50-90 micro m for canines ,8-
10 micro m for premolars and 40-80 micro m for molars.
( Muhlemann et al 1960 )
51. Gradings
• Grade I- slight more than normal upto 1mm buccolingually
• Grade II – moderate mobility (< 2mm) buccolingually and
mesiodistally.
• Grade III – severe mobility faciolingually / mesiodistally
combined with vertical displacement
52. Fremitus test
Measurement of vibratory patterns of teeth when teeth are
placed in contacting position and movements.
Test : a dampened index finger is placed along buccal and
labial surface of maxillary teeth . Patient asked to tap teeth
together in maximum intercuspal position and then grind in
lateral , protrusive movements .teeth displaced by patient in
these positions are identified.
53. Grades
• Class I fremitus- mild vibration .
• Class II – easily palpable vibrations but no
visible movememts
• Class III – movements visible with naked eyes.
• Used to diagnose TFO
54. Furcation involvement
Invasion of bifurcation of multirooted teeth by PDL disease .
Radiographs and nabers probe used for diagnosis .
55. The concavity—just above the furcation
entrance—on the root trunk can be felt
with the probe tip; however, the
furcation probe cannot enter the
furcation area.
The probe is able to partially enter the
furcation—extending approximately one
third of the width of the tooth—but it is
not able to pass completely through the
furcation.
GRADE I
GRADE II
56. In mandibular molars, the probe passes
completely through the furcation
between the mesial and distal roots.
In maxillary molars, the probe passes
between the mesiobuccal and
distobuccal roots and touches the palatal
root.
Same as a class III furcation
involvement except that the entrance to
the furcation is visible clinically owing
to tissue recession.
GRADE III
GRADE IV
57. By Hamp et al 1975
Grade 0: No involvement of the furcation.
Grade I: The furcation is detectable with a probe, but no more
than 1/3 is exposed.
Grade II: The probe can penetrate more than 1/3 of the
furcation, but not pass right through the tooth.
Grade III: The probe passes from one side of the furcation to
the other.
58. This subclassification takes into account the number of
millimeters of vertical bone loss from the roof of the furcation
apically. The following subclasses are suggested
Subclass A: 0-3 mm of probable depth from roof of the furca.
Subclass B: 4-6 mm of probable depth from roof of the furca..
Subclass C: 7 mm or greater probeable depth from the roof of
the furca.
59. conclusion
Periodontal disease is considered a sight specific
disease characterised by local inflammatory reaction to
bacterial infection . Problems often arise when
attempting to make a diagnosis of disease when using
data collection technique . So research and and
periodontal community are looking for better technique
to aid in detection and diagnosis of periodontal disease.
