This document discusses advances in periodontal diagnostic techniques. It begins by describing traditional diagnostic methods based on physical examination and signs/symptoms. It then explores developments in clinical diagnosis including methods to evaluate inflammation like gingival bleeding and crevicular fluid flow. The document also examines advances in imaging technologies and characterization of host response. Advances in probing devices are covered, moving from manual probes to computerized probes that provide precise, standardized measurements with controlled probing force.

2. Advanced diagnostic aids in
periodontics
-other than microbiological aspect

3.  Introduction
 Characteristics of Diagnostic tests
 Advances in clinical diagnosis
 Advances in imaging techniques
 Advances in host response characterization
 Conclusion
Contents-

4.  Diagnosis in periodontics responded to changes in technology & new ways of
understanding pathophysiology of periodontitis.
 Earliest diagnostic procedures based on physical
signs & symptoms
 Host response , genetic susceptibility to
periodontal disease , newer diagnostic methods
constantly evolving
Introduction

5.  Burkett (1959):
systematic examination – identify disease / disease
process
◦ CLINICAL EVALUATION
◦ PHYSICAL EXAMINATION
◦ RELEVANT INVESTIGATIONS
Diagnosis ?

6.  Determine - Cause of disease
 Plan - Treatment options
 Predict - Outcome of disease after treatment
 Determine - Duration of treatment
Diagnostic test

7. A
(true -
positive)
C
(false –
positive)
B
(false –
negative)
D
(true –
negative)
Scientific evaluation
Disease present Disease absent
Test – positive
Test – negative
Sensitivity  a/ (a + c) Specificity  d/ (b + d)
Positive predictive value
 a/ (a + b)
Negative predictive value
 d/ (c + d)

8.  Current periodontal practice  procedures -
routine periodontal examination – sufficient to
identify the pathologic changes
 Inflammation, pockets, local factors, loss of
attachment and bone
 Single visit examination – do not determine if
sites are currently undergoing additional
attachment loss

9.  Prognostic device / test  intended to assess risk of
developing disease at some point in future
 Absolute risk  develop adverse outcome – over specified
time
 Relative risk  ratio of disease in exposed group to the risk of
disease in unexposed group
 Odds ratio  odds of having the exposure, if disease is
present divided by odds of having exposure when disease is
absent

10.  Clinical & radiographic techniques not precisely
accurate e.g. periodontal probing to measure
attachment loss
 Full mouth recording for episodic nature of
periodontal disease
Y need for advances?

11.  Retrospective information about past disease cannot
diagnose disease activity
 For research purposes more accuracy in diagnosis
required

12.  Degree of gingival inflammation
◦ Gingival bleeding
◦ Measurement of GCF flow
◦ Gingival temperature
 Connective tissue destruction
◦ Periodontal probes
◦ Mobility
CLINICAL DIAGNOSIS

13.  Evaluation of degree of inflammation - assessment
◦ Redness
◦ Swelling
◦ Gingival bleeding
 Gingival bleeding
◦ Related - persistent presence of plaque
◦ Regarded - sign of associated inflammatory process
(Greenstein, Caton, Polson - 1981)
Gingival bleeding

14.  Gingival bleeding as indicator of inflammation
◦ OBJECTIVE
◦ GOOD INDICATOR – presence of inflammatory lesion in CT
◦ Indicator – disease activity
◦ Progression – unclear
(Polson, Caton 1985)

15.  Lang et al (1991):
◦ Retrospective study
◦ Sites that bled at several visits –had higher probability
of loss of attachment
◦ Limitation – healthy sites may bleed
◦ Force - > 0.25N – evoke bleeding in healthy sites
 BOP – limited predictable value for disease progression
 Absence of BOP – periodontal stability with high
probability

16.  Ciancio (1986), Greenstein (1984), Muhlemann
(1971):
increase GCF + bleeding = earliest signs
 Brill (1960), Loe (1963, 65):
increase volume of GCF – with increase severity of
inflammation
Gingival crevicular fluid flow

17.  Formed basis of readings in PERIOTRON ® 600
Periotron reading Level of gingival
inflammation
Gingival index
0 – 20 Healthy 0
21 – 40 Mild 1
41 – 80 Moderate 2
81 – 200 Severe 3

18.  Periotron 600 (1976) – 0.5
micro L
 Peritron 6000 (1983) - 1
micro L
 Periotron 8000 (1995) -
3 micro L

19.  Other measures – when clinical signs are UNRELIABLE
 Subgingival temperature
Gingival temperature

20.  Kung et al (1990): - PERIO TEMP®
◦ Similar to conventional probe
◦ Time < 1 sec
◦ Sensitivity 0.1degree
No change with local environment
◦ Diseased sites - > temperature
◦ Posterior sites – warmer
◦ Mandibular arches – warmer
Increase periodontal inflammation
Increase in cellular and molecular activity

21.  Haffajee et al (1992):
◦ Increased subgingival temperature – related to LOA in shallow
pockets
◦ Increase periopathogenic organisms – sites with increased
temperature

22.  Benson, Khan (2005):
◦ Infrared Thermometer
(THERMO SCAN)Vs Periotemp ®
◦ Buccal aspects of 8 teeth
◦ Similar reliability between the
groups
◦ Practical alternative

23.  Imp clinical manifestation of advanced periodontal
disease
 Muhlemann (1954, 1960)
◦ PERIODONTOMETER
◦ Small standard force – 100 pounds – applied to crown
◦ Resilience – initial movement – 0.05 – 0.10 mm
◦ Larger force – tooth movement in different areas
Tooth mobility

24.  Schuttle (1992):
◦ PERIOTEST system
◦ Reaction of periodontium
◦ Speed – 0.2m/s, contact time – 0.3 -0.2milisec
◦ Scale
- 8 to +9 Firm
10 to 19 First sign
20 to 29 1mm from
normal
30 to 50 Ready mobility

25.  Implants
Periotest value
range
Interpretation
-8 to 0 Good
osseointegration
+1 to +9 Clinical examination
required
+10 to +50 Poor
osseointegration

26.  Clinical periodontal probe - widely used diagnostic tool
for clinical assessment
Conventional manual periodontal probe
 Probe
◦ Fine – narrow periodontal pocket
◦ Blunt end – reduce penetration
of tissues at base
Periodontal probing

27.  The size of the probe
 The angulation of the probe
 The contour of the tooth & root surface
 Probing force used
 Inflammatory state of the tissues
Factors affecting accuracy (Listgarten et al 1976)

28.  Listgarten et al (1976,1980) ; van der Velden
(1979)
◦ Pdl probing – fails – true pocket depth
◦ Discrepency b/n actual position of probe and true base
of pocket (histologic sections)
 Gabanthler and Hassell (1971), Hassell et al
(1973)
◦ Force (3 – 130 g )  used by different clinicians
◦ Differs by same clinician from 1 examination to other

29.  > probing force  > probing depth measured
 To limit errors due to differences in probing forces Polson et al
(1981) - pressure sensitive probes
 Armitage et al (1977), Robinson and Vitek (1979),Polson et al
(1980)
◦ Inflammation  overestimation of true pocket depth
◦ Force – 30g  probe within JE
 Kalkwarf et al (1986)
◦ force 50g  osseous defects

30.  Listgarten et al (1980)
◦ Health/ following therapy  underestimation of true pocket
depth
 Haffajee and Socransky (1986)
◦ Manual probing cannot reliably measure changes in probing
pocket depth of less than 2.5 – 3mm

31.  G.V Black (1924) - described systematic use of probe
 Simonton (1925) –
 Merritt (1931)-
 Pihlstrom (1992)- generations of
probe
Generations of probes
University of
Carolina
Periodontometers

32. Marquis colour coded probe
• Caliberation – 3mm sections
• 3-3-3-3, 3-3-2-3 or 2-2-2-2mm
UNC – 15 probe
• 15mm long , mm marking at each mm
• Colour coding – 5,10, 15 mm
University of Michigan “O” probe
with Williams makings
• Marking at 1,2,3,5,7,8,9
1st Generation probes (manual)

33. Michigan “O” probe
• Round fine diameter at tip
• Markings at 3,6, 8 mm
WHO probe
• 0.5mm ball, mm marking at 3.5,
5.5 and 8.5, and 11.5
• Colour coding  3.5 – 5.5
• CPITN C and CPITN E

34.  C. H. Williams (1936, 1943)
 13mm long thin stainless steel tip
 Rounded tip end
 mm markings at 1,2,3,5,7,8,9,10
 Probe tip and handle- 130 degrees
Williams’ probe

35. Goldman
Fox
• Williams
markings
• Flat tip
Glickmans
probe
• Round tip
• Long shank
Meritt A
and B
• Round tip
• Single
bend in
shank

36. • 1/10th of mm
• Modification of model boley gauge
• A mm measuring rule, Vernier
gauge, 0.020 orthodontic wire, tube
of 14 gauge stainless steel
• Reading accurate to 0.1mm
Steven S
Detsch
(1976)
• 0.5mm diameter tip, rounded
end
• Marked increments upto 20mm
• Thick black markings – 4,9, 14
and 19 mm
LL 20 probe
(Hu- Friedy
USA)

37.  Nabers probe
◦ Noncalibrated, curved
◦ 1N and 2N
Variations –
◦ 3N with Markings –
1,2,3,4,5,6,7,8,9,10
◦ Colour coding – 3,6,9, 12

38.  Gabathuler and Hassel (1971)
◦ Developed in response to “Gentle sulcus probing”
◦ Miniature piezo- electric pressure sensor mounted on
standard periodontal probe connected to an amplifier and
dynagraph writer.
◦ Force – 20.2 to 32.6 pounds
Hassel et al (1973)
◦ Loose correlation - force and depth
◦ Probing technique – more imp than force
Second generation probes

39. Armitage et al (1977): Pressure sensitive holder to
 standardize insertion force
 Accuracy to measure CT attachment levels
25 pounds –
◦ healthy gingiva  failed to reach JE
◦ experimental gingivitis  close to apical termination
◦ periodontitis  went past most apical cells of JE

40. Other controlled force delivery probes
◦ Van der Velden and De Vries (1978) – “pressure probe” cylinder and piston
connected to an air pressure
◦ Vitek et al (1979) – leaf spring force controlled
◦ Tromp et al (1979) – constant torque spring
◦ Van der Velden and De Vries (1980)
- displacement transducer for electronic
read out
- force produced through coil spring

41. Vine Valley Probe ( Vine valley research NY, USA)
◦ Polson et al 1980
◦ Not sensitive to lateral forces
◦ Pressure force with range of sensitivity – 5 to 100 grams
◦ Different types of probe tips
Viva Care TPS Probe (Vivadent)
 Hunter F (1994)
 Disposable probing head
 Tip – hemisphere, diameter – 0.5mm, rim – detection of
CEJ, overhangs, irregularities of root form
 Controlled probing Force – 20gram

42.  - Controlled force application
- Automated measurement
- Computerized data capture
Third generation probes

43.  Jeffcoat Probe/Foster Miller Alabama Probe :
Jeffcoat et al (1986) - detects CEJ automatically
 Pneumatic cylinder, linear variable differential transformer,
force transducer, accelerometer and the probe tip
 Measures CAL within 0.2 mm
 Birek’s Probe : (Birek et al 1987)
◦ Nitinol wire 0.5 mm diameter enclosed in a polyethylene
sheath
◦ Propelled by constant air pressure
◦ Probe angulation was consistent
◦ uses occlusal surface/ incisal surface as reference

44.  A precision of ± 0.1 mm
 Range of 10 mm
 A constant probing force
 Non invasive, light weight, easy to use
 Able to access any location around all teeth
 Guidance system to ensure reproducible pathway
 Digital output
 Complete sterilization of all portions entering mouth.
 No biohazard from materials or electric shock
NIDCR criteria

45.  probe hand piece + digital readouts +
foot switch + computer interface +
computer
 Tip – similar to Michigan “O” probe,
hemispherical, 0.4mm diameter
 Tip – reciprocates through sleeve ,
edge – reference point
 Reference sleeve- 0.6mm
Florida probe system
(Gibbs et al - 1989)

46. Modifications
Florida stent
probe
- 1mm metal
collar
- Ledge of a
stent
Florida disc
probe
- 11 mm disc
-
incisal/occlusal
surface
Florida PASHA
probe
- Modified
Sleeve
- 0.125mm
edge
- “Catch” of
CEJ

47. Florida stent probe
Florida disc probe
Florida PASHA probe

48.  Toronto Automated Probe
◦ (Karim et al 1990)
◦ Tilt sensor device – change in angulation
◦ Force 10 – 90 gms – precise reproducible probing force
 Interprobe
◦ (Goodson & Kondon 1988)
◦ Fiberoptic technology

49.  PERIPROBE COMP ( PD International AB Swedish )
◦ Disposable probe sleeve unit
◦ Ball shaped end point of 0.5mm diameter
◦ Hand piece – spring – controls probing pressure
◦ 0.45 N in 2mm pocket to 0.25 N in 13 mm pocket
◦ Hand piece connected to computer

50.  LIMITATIONS OF AUTOMATED PROBES (Perry et al
1995)
◦ Lack of tactile sense
◦ Patient discomfort – fixed angulation & pressure
◦ Underestimation of pocket depth

51.  Fourth generation probes :
Sequential probe positions along gingival sulcus
 Fifth generation probes :
Added ultrasound device to third generation

52.  PERIOSCOPE
 Designed to explore & visualize pocket
 Fiber optic technology
Dental endoscope

53. • 0.99mm reusable fiberoptic endoscope over which is
fitted a disposable sterile sheath
• Fits into probes and ultrasonic instruments
• Sheath delivers water irrigation – flush pocket – keep
field clean
• CCD video camera - image on monitor
• Magnification – 24 to 46 times

54.  Advantages
◦ Increased effectiveness of nonsurgical therapy
◦ Increased diagnostic accuracy  leading to increased
appropriateness of Rx methods
◦ Increase effectiveness of surgical therapies which were limited
by visibility problems

55.  PERIOWISE –
◦ friendly periodontal probe
◦ Patented, multi- coloured probe
◦ Easy to read
◦ Gentle on tissues
◦ Safe to use around implants
◦ Markings in red and green
Advances

56.  DIAMOND PROBE/ PERIO 2000
SYSTEM
(Diamond Gen Dev Corp ,USA)
 Combines features of
periodontal probe with detection
of volatile sulphur compounds in
the periodontal pocket
 Lack of longitudinal studies

57.  Impact of radiographic imaging  unchanged
 Substantial advances in X-ray generator and
detector  dose reductions and improved
image quality
RADIOGRAPHIC DIAGNOSIS

58.  Accepted widely  aid for diagnosis and Rx
 Main purpose
◦ Level of alveolar bone (pattern and extent of bone
destruction)
◦ Quantify bone levels and osseous defects
◦ Pdl space, lamina dura, periapical area, calculus, defective
restorations
◦ Baseline information
Y imaging?

59.  Intraoral / extraoral
What type of imaging?
Limitations
• 2 dimensional representation
• Superimposition
• Only assessment of interproximal bone level
• 2 wall and 3 wall defects – no accurate
quantification
• Substantial mineral loss (30 – 50 %)
• Specific but not sensitive

60.  Simple to acquire, low cost
 Pt dose is low
 Ways to reduce pt dose
◦ Use fast image receptor (E or F speed films and digital
detectors)
◦ Rectangular collimation (50- 80 % - dose reduction)
Intraoral radiography

62.  Standardization of radiographs
Rosling et al 1978
◦ Constant film position – film holders, stents
◦ Constant tube geometry - Positioning devices (Rinn
system) Cephalostat (Jeffcoat et al 1987)
◦ Using paralleling techniques

63. ◦ Using vertical bitewings
◦ Use 90 kVp
◦ Using superimposed mm grid
◦ Using root length ruler - Shei ruler

64.  Useful image modality
 Fast image acquisition, simple, without need for any intraoral manipulation.
 All dentoalveolar structures in a single image- low dose.
Disadvantage:
◦ Image distortion
◦ Less detailed image (ghost images)
 Alternative for full mouth periapical radiographs
Extraoral radiography

65.  Been on market for 15 years and evolution has made it
a viable alternative to film- based imaging.
Digital radiography

66.  Digital radiography  method of capturing a radiographic
image using a sensor, breaking it into electronic pieces and
presenting and storing the image using a computer.
Radiation exposure-
 Less X-ray irradiation
 Less exposure time
 Lower absorbed dose

67.  Direct digital imaging
 Indirect digital imaging
 Storage phosphor imaging
Methods to obtain a digital image

68.  “Digital ”  numeric format of image content as well
as its discreteness
 Numeric and Discrete-
◦ Pixels (spatial distribution of picture elements)
◦ Shades of gray of each pixel
 “Digital image”  collections of individual pixels
organized in a matrix of rows and columns

69. Direct digital
imaging
Solid state
detectors
CCD (e.g. RVG)
Complementary
metal oxide
semiconductor
(CMOS)
Indirect digital
imaging
Photostimulable
phosphor
PSP with
external laser
scanner
Technologies for implementation

70. Disadvantages-
 Sensor placement is more challenging- thick and rigid
with a cable attachment
 Patient discomfort
 More time consuming- plates scanned and reused
F speed film, PSP, CCD Sensor, CMOS sensor

71. ◦ Elimination of chemical processing
◦ Shorter exposure to display time
◦ Integrated with existing electronic office and
patient management systems
◦ Enhanced image quality
◦ Reduced dose of radiation 1/3rd to ½
Advantages:

72.  Based on use of CCD
 Duret F et al (1988)
 3 parts
◦ Radio – X-ray generator connected to sensor
◦ Visio – stores incoming signals during exposure and
converts to gray levels
◦ Graphy – digital mass storage unit – connected to various
video printout devices
Radiovisiography (RVG)

73. Radiographic digital
detector
Conventional radiographic
source to expose sensor
Detector converts X-rays to
visible image
Image display on monitor
Mechanism of image display

74.  Mouyen F et al (1989):
◦ Physical properties of conventional films & images from RVG
◦ RVG –use reduced levels of radiation
 Fukart et al (1992):
◦ Diagnostic accuracy of D-speed and E-speed films with that of Sens-
A-Ray sensor system – interproximal bone lesions
◦ No difference
 Khocht A et al (2003):
◦ Estimates of bone level – digital and conventional
◦ Difference
◦ Digital not a substitute

75. Advantages- Disadvantages-
 Immediate image display
 Avoids interruption for film
processing
 Direct manipulation of image
 Reduced patient radiation
 Image processing- gray level
can be adjusted
 Positioning uncomfortable
 Loss of resolution from
screen to print
 High cost of the equipment

76.  Zeidses des Plantes (1935) : 1st demonstrated use of subtraction
imaging
 Grondahl et al (1983): in dentistry
 “Noise”
 Ando (1969): conversion of dental radiographs into digital format
 Webber (1981), Groendahl (1981): video and computer technology
Digital subtraction radiography

77. 2 images are
registered
Image intensities of
corresponding pixels are
subtracted
Uniform difference image

78.  Brighter area  gain
 Darker area  loss
 Strengths  cancels out complex anatomic
background against which this change occurs. As a
result, conspicuousness of change is greatly increased

79. Ortmann (1994) 5% of bone loss can be detected.
 Diagnostic subtraction radiography (DSR)-
 for enhanced detection of crestal or periapical bone density
changes and to evaluate caries progression
 Nummikoski et al. (2000)- DSR vs conventional – gain in
diagnostic accuracy

80. Advantages Disadvantages
 Overall contrast is improved
 Trabecular fine marrow
spaces are clearly visualized
 Low and high density
images are equally
enhanced
 No objective description
 To achieve high degree of
standardization, occlusal
moulds necessary
 No reduction in pts
exposure to X-rays

81.  Bragger et al (1988)
 Video camera  measures light transmitted through
radiograph  signals from camera  gray scale images
 Interfaced with an Image processor and computer
 Objective method– changes in alveolar bone densities
quantitatively over time
Computer assisted densitometric image analysis (CADIA)

82.  High sensitivity and degree of reproducibility
and accuracy
 CADIA values
◦ Values within ± 6.6  insignificant change
◦ <- 6.6  density loss
◦ > +6.6  increase in density

83. Bragger et al (1987):
 alveolar bone density changes by perio surgical procedures
and during healing phase-
 Capable of assessing differences in resorptive activity over a
period of time.
 Bragger et al (1989):
◦ Alveolar bone changes in furcations – CADIA
◦ 21 pts – immediately after, at 1,6 and 12 months after
periodontal surgery
◦ 1 month  > density loss
◦ CADIA – valuable additional diagnostic information
regarding alveolar bone density

84.  Benn (1992)
◦ Computer aided method for making linear measurements
on radiographs using stored regions of interest
◦ Radiographs are calibrated and digitized
◦ Region of interest (ROI) 7.5 x 7.7mm area
◦ Calculate difference in both films
Computer assisted linear radiology

85.  Process by which image layer of body is produced,
while images of structures above and below that layer
are made invisible by blurring
◦ Conventional tomography
◦ Computed tomography
◦ Emission tomography
Tomography

86.  Body section radiography/ tomography
 Images more clearly the objects lying within a plane of
interest
 Brought about by blurring of images above and below
the plane of interest
 Techniques – based on direction in which X-ray source
and film move
Conventional tomography

87.  Godfrey Hounsfield and Allan
MacLeod Cormack (1979)
◦ Computerized axial tomography
◦ computed tomographic
scanning
◦ axial tomography
◦ computerized transaxial
tomography
Computed tomography

88.  Digital & mathematical technique – creates tomographic sections
 layer, not contaminated by blurred structures
 Differentiation and quantification of both hard and soft tissues
 Non invasive
 CT machines – rotating fan beam –image 1 slice of pt at a time –
axial orientation
 Modern CT machines – continuous table motion during image
acquisition – spiral/ helical image formation patterns

89.  Image volume generated – slices can be reconstructed -
multiplanar reformatting (MPR)
 Software applications
 Limited ability – small details (not more than 1-2 mm )
 Unfavorable cost- benefit ratio
 Ito et al. (2001)-
CT provides 3 D images of excellent quality for evaluating
morphology of periodontal bone defect and furcation
involvement after regenerative therapy

90. Advantages Disadvantages
 Eliminates superimposition of
images of structures outside area
of interest
 High contrast resolution –
differences between tissues that
differ in density < 1% - can be
distinguished
◦ Pixels that form image –
represent subdivisions of
space – blurring more
evident
◦ Fine Details lost
◦ Metallic objects-artifacts
◦ Expensive

91.  Dentascan ®
Specialized software
program for multiplanar
dental reformations using
series of axial CT scans

92.  Select axial scan – draw curved line parallel to axis of
alveolar ridge  allowing for automatic 2 dimensional
reconstructions
◦ 1 –parallel to alveolar ridge
◦ 2 –cross sectional view perpendicular to curvature of
alveolar ridge

96.  SIMPLANT ®
◦ Computer program for assessing oral
implant site
◦ Manipulates the reformatted
Dentascan- type images
◦ Advantages:
assessment of bone volume, quality
and biomechanical analysis of
proposed prosthetic restoration

97.  Motivation behind development was the need to assess dentoalveolar
tissues in 3 dimensions
 Principle of TOMOSYNTHESIS
 By shifting and combining set of basis projections, arbitrary slices
through the object brought into focus
Tuned aperture computed tomography (TACT
®)

98.  Basis projections – conventional radiographs
 Slice – 2 dimensional representation
 Ramesh et al. (2001)-
TACT vs conventional film for simulated periodontal
defects- better diagnostic performance.
Nair MK et al. (2007)-
TACT vs conventional CT for evaluation of osseous healing
Comparable performance to CT.

99.  Advantages
◦ Use existing dental equipment
◦ Low cost
◦ Low dose
 Uses
◦ Imaging alveolar bone
◦ Detect osseous defects
◦ Pre-operative imaging of implant site

100.  Cone shaped beam – to acquire entire volume in single
pass around pt
 Advantage
◦ Less radiation exposure
◦ Less expensive
 Disadvantage
◦ Increase effect of scatter radiation (reduces contrast)
◦ Imaging of hard tissues only
Cone beam computed tomography (CBCT)

101.  Lascala CA et al 2004
◦ evaluated NewTom 9000 for accuracy of the linear measurements
obtained in CBCT.
◦ It is reliable for evaluation of structures more closely
associated with dentomaxillofacial imaging.
 Mol A and Balasundaram (2008) –
Evaluated The NewTom 9000 CBCT scanner - better diagnostic and
quantitative information on periodontal bone levels in three
dimensions than conventional radiography.

102. ◦ Misch et al. (2006) CBCT vs traditional methods for perio defects
◦ No significant difference between these modalities
◦ Advantage- defects were detected and quantified
◦ Walter C (2009)- (CBCT) in assessing furcation involvement and concomitant treatment
decisions in maxillary molars.
◦ 12 pts with CP
◦ Discrepancies between clinically and CBCT-based therapeutic treatment approaches were
found in 59–82% of the teeth.

104.  Form of CBCT
 Uses a small-field high-resolution detector to generate
limited high-resolution 3D volume
 Generates exquisite image detail in 3D
 Low pt dose and cost
Local computed tomography

105.  Technology is still relatively new and commercial
availability is limited
 Very promising modality for imaging alveolar bone for
assessment of-
◦ Bone destruction
◦ Implant site assessment

106.  Huang et al. (1991)
 Generates cross-sectional images of biological tissues using a near-
infrared light source
 Light penetrates into tissue without
biologically harmful effects
 Difference in reflection of light –
generates signal – corresponds to
morphology and composition of underlying tissue
Optical Coherence tomography

107.  Particularly suited for ophthalmic applications
 Otis et al. (2000)- 1st intraoral dental image
Xiang et al. (2009)
 OCT imaging can offer three-dimensional imaging of periodontal
soft tissues and bone at exquisitely high resolution .
 it offers the potential for identifying active periodontitis before
significant alveolar bone loss occurs
 It may prove to be a more reproducible and reliable method for
determining attachment level

108.  Does not use ionizing radiation
 To image soft tissue
 Advantage  Noninvasive
Magnetic Resonance Imaging

109.  Limitations
◦ Expensive
◦ Requires considerable scan time for high
resolution image
◦ May be claustrophobic to pt
◦ Artifacts due to metal

110. Pt placed in strong magnetic field
Protons of hydrogen nuclei of the water
within tissues rotate like a spinning top
Resonance frequency energy – applied
and removed
Response of nuclei – observed in
reservoir coil
Mathematical algorithms – reconstruct
slices / planar images

111.  Henrikson 1967
◦ non radiographic method
◦ Absorption by bone of low energy gamma beam from
radioactive source I 125
◦ Sensitive in analyzing bone mass changes
 Hausmann et al 1983
◦ Measures bone mass with high accuracy & precision
I 125 absorptiometry

112. Limitations :
 Technical factor limits usage in posterior areas
 Nature of beam I 125 makes precise alignment critical
Dexa Scan or DXA Scan – bone densitometry
-Dual energy X ray Absorptiometry

113.  Nuclear medicine  radiolabeled pharmaceuticals to
image particular organs or to detect specific disease
processes
 For diagnosis of periodontal disease  used to
detect sites of active bone loss
 Technetium- labeled – disphosphonate
Nuclear Medicine Techniques

114.  Disphosphonate  bone seeker – gets adsorbed onto
forming front of bone
 Detects alteration in bone metabolism
 Agent – injected intravenously
- allow time for bone uptake
- imaged using gamma camera/ detectors
- areas of active bone loss  “hot spots”

115. Diagnostic tests have been developed that
add measures of the inflammatory process
to conventional clinical measures
HOST RESPONSE CHARACTERIZATION

116.  Provide information on
◦ Destructive process
◦ Current activity
◦ Rate of disease progression
◦ Patterns of destruction
◦ Extent and severity of future breakdown
◦ Likely response to therapy

117.  Assessment of host response – study of mediators that
are recognized as a part of individuals response to
inflammation
 Antibody to putative pathogens
 Host-derived enzymes
 Inflammatory mediators
 Tissue breakdown products

118. Proteases and enzymes
 Aspartate aminotransferase
 Alkaline phophatase
 β –glucuronidase
 Elastase
 Matrix Metalloproteinases
Host Derived Enzymes

119.  Nakamura & Slots 1983 observed increased activity
of:
- Alkaline phophatase
- Elastase
- β –glucuronidase
- α-β- glucosidase
- Aminopeptidases
IN PERIODONTITIS

120.  Ozmers et al 2000 – found higher concentrations of
arginase in chronic periodontitis patients compared to
healthy subjects.

121. • Zambon 1985
After periodontal therapy there was reduced amounts
of valine, cysteine, aminopeptidases, lipase ,trypsin ,β
galactosidase and β glucosidase

122.  Matrix Metaloproteinases (MMP) & TIMP – 1 levels in
saliva
◦ MMP -9 significantly higher in periodontitis patients (
Makela 1994 )
◦ TIMP – 1 concentration significantly lower in
periodontitis patients than normal patients

123.  Salivary platelet activating factor – Rasch 1995
found to be reduced post periodontal therapy
 Nitric Oxide – Aurer 2001.
Conc increased in patients with chronic & aggressive
periodontitis
 Salivary Glycoprotein - Krager 1987.
Increased in patients with periodontitis

124.  Relation between antibodies and periodontal infection
Ebersole 1995,Tato 1998
◦ Elevated levels of IgG , IgM, IgA found in saliva in
periodontitis patients to bacteria like P. Gingivalis &
Aa

125.  Salivary orogranulocytes
 Used to identify specific risk factors in them from
saliva.
 Neutrophils isolated from saliva had deficient
glycoprotin receptors such as Mac-1, P 150,95.
Kinane & Lappin 1999.
 Orogranulocytes have reduced levels of L –
selectin Garnett 1999

126.  Other proposed diagnostic markers –
◦ host proteins,
◦ enzymes
◦ hormones (cortisol )
◦ Volatile compounds and ions

127.  GCF  large repertoire of serum proteins,
inflammatory mediators, host cell degradation
products and microbial metabolites
 A variety of enzymes that degrade proteins,
proteoglycans, lipids and carbohydrates have been
detected in GCF
Gingival crevicular fluid

128.  Components – novel indicators
 Guide clinician - early detection and monitor tissue health
 Biomarker- a substance that is objectively measured and evaluated as an indicator
of normal biologic processes, pathogenic processes, or pharmacologic responses
to a therapeutic intervention.
 Ideal diagnostic marker  indicate presence of disease before extensive clinical
damage has occurred
 High specificity

129. Periocheck (ACTech)
• Neutral proteinases – COLLAGENASE
• Paper strip – for GCF sampling
• Placed in contact with collagen gel – bound
with blue dye
• 43 ° C – incubation
• If present – attack collagen gel and release
blue dye
• Color Intensity – proportional to amount
• Intensity – scale 0-2
Commercial diagnostic kits

130. Prognostik (Dentsply)
• Serine protease- ELASTASE
• Paper strip
• impregnated with peptidyl derivative of 7
amino-trifluoromethylcoumarin (AFC)
• Substrate linked to fluorescent leaving group
• Reaction- 4-8mins
• Green fluorescence
• UV light

131.  Aspartate aminotransferase- a tissue destruction
biomarker
 AST —positively correlated with higher prevalence of P
gingivalis, Strep intermedius, Peptostreptococcus
micros, Bacteroides forsythus, C gracilis and C rectus.
Cytosolic enzymes

132. Periogard (Colgate)
• ASPARTATE AMINOTRANSFERASE
• Paper strip – placed in trimethane
hydrochloride buffer
• Substrate – L-aspartic & α-ketoglutaric acid
• Catalyzed to oxalacetate and glutamate.
• Dye is added – coloured product
• Positive test - ≥ 800 mIU AST activity

133.  Pocket watch (Steri-oss®, Yorba Linda, California, USA)
◦ Qualitative test determines presence of large amounts of
(AST) in gingival fluid.

134. Advantages
• Predictive of
disease activity
• Simple (colour
detection)
• Short time
• Can be shown to
pt
Disadvantages
• Choice of
biomarker still
difficult
• When and which
sites
• Cost

135. Ora Sure (OraSure Technologies ,Pennsylvania)
HIV diagnosis collects HIV-1 Antibodies from buccal
mucosa and gingiva
Geno Type PST™ Plus –
Interleukin Genetics .IL -1 alleles IL 1 α +4845 and IL –1β +
3954.“genotype positive”

136. Micro Analyzer
Futuristic chair side diagnostic test based on GCF sampling. “Mini lab”

137.  Toxic Pre screening Assay (TOPAS) Test
◦ Measures levels of endotoxins & proteases in GCF
◦ Chair side test, easy patient education tool
◦ Measures efficacy of treatment protocols

138.  In the field of oral diagnostics , there has been steady growing trend from
last two decades to develop tools to monitor periodontitis.
 Physical measurements such as periodontal probing to sophisticated
genetic susceptibility analysis & molecular assays for detection of
biomarkers at various stages of disease.
 All these have to be correlated with clinical signs
Conclusion

139.  The advent of digital imaging such as RVG, DSR and CADIA etc.
have further improved our basic diagnostic armamentarium as
these aid in quantifying minor bone changes.
 Developments  translated into meaningful clinical
applications improving the way we prevent, diagnose and
treat
 Increased synergism between technology & fundamental basics
,added impetus to the new paradigm of periodontal diagnosis.

140. hank you !