3. Introduction
What is diagnosis?
Categories of periodontal diseases.
The gingival diseases
Various types of periodontitis
Periodontal manifestation of systemic diseases.
First visit
Second visit
Clinical examination
Extra oral -
Intra oral
Oral hygiene
Quality and quantity of saliva
Halitosis
Soft tissue examination
4. Examination of periodontium
- Introduction
- Plaque and calculus
- Gingiva
Tension test
Width of attached gingiva
Clefts
Periodontal pockets
Clinical indices
Gingival index
Russel’s periodontal index
Calculus index
Debris index
Determination of disease activity
Alveolar bone loss
Palpation
Suppuration
Abscess
The periodontal screening and recording system
5. “Diagnosis” is the ability and skill of the
clinician to detect, recognize, and know the
nature of the disease process
– in other words, to be familiar with the
qualities, the behavior, and the development
(pathogenesis) of the abnormality
6. Proper diagnosis is essential
to intelligent treatment.
Proper evaluation of history of the disease process
Signs & symptoms present
Laboratory data
Special tests & radiographs
The value of establishing a diagnosis
is to provide a logical basis for
treatment & prognosis
7. Periodontal diagnosis should first determine
whether disease is present, then identify its
type, extent, distribution & severity and
finally provide an understanding of the
underlying pathologic process and its cause.
9. ENERAL REVIEW
DIAGNOSIS : THE PROCESS 5
data collection
G
In general diseases that can afflict the periodontium
fall into 3 broad categories.
The gingival diseases
The various types of periodontitis
The periodontal manifestation of systemic diseases
10. Classified by AAP international workshop for Periodontal Diseases (1999).
11. Classified by AAP World Workshop in Clinical
Periodontics (1989).
Adult Periodontitis.
Early Onset Periodontitis -Prepubertal
-Juvenile
-Rapidly progressive.
Necrotizing Ulcerative Periodontitis.
Refractory Periodontitis.
12. European workshop in periodontology, 1993
Adult periodontitis – age of onset forth decade of life
Slow rate of disease progression
No defect in host response
Early onset periodontitis - age of onset before forth decade of life
Rapid rate of disease progression
defect in host response
Necrotising periodontitis-
tissue necrosis with attachment
and bone loss
13. Classified by AAP international workshop for Periodontal Diseases (1999).
14. In addition, seven major categories of
destructive periodontal diseases were listed:
Chronic periodontitis
Localized aggressive periodontitis
Generalized aggressive periodontitis
Periodontitis as a manifestation of systemic
disease
Necrotizing ulcerative gingivitis/periodontitis
Abscesses of the periodontium
Combined periodontic–endodontic lesions
15. Tooth-related factors that modify or predispose
to plaque-induced gingival diseases/periodontitis
Tooth anatomic factors
Dental restorations/appliances
Root fractures
Cervical root resorption and cemental tears
Mucogingival deformities and conditions
Gingival/soft tissue recession
Facial or lingual surfaces
Interproximal (papillary)
Lack of keratinized gingival
Decreased vestibular depth
Aberrant frenum/muscle position
Gingival excess
Pseudopocket
Inconsistent gingival margin
Excessive gingival display
Gingival enlargement
Abnormal color
Occlusal trauma
Primary occlusal trauma
Secondary occlusal trauma
16. Following is a recommended sequence of procedures
for the diagnosis of periodontal diseases.
FIRST VISIT:
Overall Appraisal of the Patient:
• Consideration of the patients mental
and emotional status,
• temperament,
• attitude
• and physiologic age
17. Personal information
Name-Full name includes pt’s name, father’s or husband’s name and surname
For -Record
Communication and
Certification.
Age-Recorded in years
Importance-In case of periodontal disease helps in diagnosis of
puberty gingivitis, ANUG, Prepubertal periodontitis,
Juvenile periodontitis and Adult periodontitis.
Sex
Importance -Hormonal disturbances during puberty,
menstrual period & pregnancy modifies tissue response
to local irritation in females.
-Certain systemic conditions also seen with significant
sex difference( e.g. hemophilia in male)also affects
overall condition.
18. Residence- This should be noted in details mentioning the
house number,street, society, city or village, pin
code and district. Previous visit or residency also
noted.
Importance - Due to high fluoride content in water fluorosis is
more common in certain regions.
-Also gives information about convenience of patient
for recall visits.
Occupation- Both the present and past occupations should be
noted.
Importance -Erosion is commonly seen in persons
associated with acid fume works.
-Some occupational habits (e.g. holding nails by
anterior teeth in carpenters, shoe makers and
tailors.) causes notching of incisal edges of maxillary
incisors.
19. Medical History:
Most of the medical history is obtained at the first
visit. Health history can be obtained verbally by the
questioning of the patient.
Importance of medical history should be explained to
the patient.
Medical history will aid the clinician in diagnosis of oral
manifestations of systemic disease, detection of systemic
conditions that may be affecting the periodontal tissue
response to local factors that require special precautions
and or modifications in treatment procedures.
20. Medical history should include reference to the
following
Whether the patient is under the care of a physician.
Name,address, telephone no. of the physician should be recorded.
Hospitalization and operations: Kind of operation, untoward
effects such as anesthesia, hemorrhagic, infectious complications.
All medications being taken : Special inequity should be made
regarding the dosage and duration of therapy with anticoagulant
and cortico steroids.
History of all medical problems :Cardiovascular,hematologic,
endocrine etc. Infectious diseases, sexually transmitted diseases,
AIDS.
Possibility of occupational disease
21. Medical history should include reference to the
following
Abnormal bleeding tendencies : Nose bleeds, prolonged bleeding
from minor cuts, spontaneous echymosis, tendency towards excessive
bruxism, excessive menstrual bleeding.
History of allergy including : Hay fever, asthma, sensitivity of foods,
sensitivity to drugs - Aspirin, Codeine, Barbiturates, Sulfonamides,
Antibiotics, Procaine, Laxatives. Sensitivity to dental materials – Eugenol
/Acrylic resin.
Information regarding the onset of puberty : Menopause,
menstrual disorders, hysterectomy, pregnancies, miscarriages.
Family medical history, including bleeding disorders and diabetes.
22. Dental history
History of current dental illness-Chief complain
Periodontal disease is so insidious that it may lack signs and
symptoms in the early and moderately advanced stages.
● Some patients may reports with
Bleeding gums.
Mobility of teeth.
Tooth migration
Foul taste and itchy feeling in gums.
Localized or generalized discomfort or teeth “feel sore” in
the morning.
23. Pain -Of varied duration.
-Constant or intermittent.
-Dull or acute throbbing pain.
-Localized or radiating pain
.
Sensitivity - When chewing.
-To heat and cold.
-To inhaled air.
Burning sensation in gums.
A preliminary oral examination is done to explore the source of the
patient’s chief complain and to determine whether immediate emergency
care is required.
24. Relevant dental history
A list of dental visits, recent visit, nature of treatment and oral prophylaxis or
cleaning by a dentist or hygienist including frequency & date of most recent
cleaning.
Patient’s oral hygiene regimen
Toothbrushing frequency.
Method of brushing.
Time of day.
Type of toothbrush or datun –
Type of dentifrice
Interval at which brushes are replaced.
Other aids.
3. Previous tooth loss due to caries or periodontal lesion may change the
treatment plan.
4. Any orthodontic treatment including duration and approximate date of
termination.
5. Pain -Whether in teeth or gum
-Manner by which provoked
-Manner in which relieved
-Nature and duration.
25. 6. Bleeding gums- Since what time
-Spontaneously, on brushing or eating.
-At night or with regular periodicity whether
associated with menstrual period or other
specific factors
-Duration of bleeding
-Manner in which it is stopped.
7. Bad taste and areas of food impaction.
8. Tooth mobility-If teeth feel loose or insecure
-Difficulty in chewing
9. Habits -grinding or clenching during day or night
-Unilateral chewing
-Mouth breathing
-Tobacco smoking or chewing
-Nail biting or foreign objects.
10. Previous periodontal problems
-Nature & condition
-If treated, type of treatment and approximate period
of termination of treatment.
-In the patient’s opinion present problem is a recurrence
of previous disease.
26. Intraoral radiographic survey
-Minimum of 14 intraoral films and 4 posterior
bitewing films.
-Panaromic radiographs more convenient.
-Provides information of distribution and severity of
bone destruction in periodontal disease.
28. -Extremely useful adjunct in the oral examination.
-Indicates-Position of gingival margins
-Position and inclination of teeth
-Proximal contact relationships and food impaction areas
-Lingual cusp relationships.
-Important before treatment record.
-Visual aids in discussion with patient.
-Useful pre and post operative comparisons as well as for reference at
check up visits.
Casts
29. Clinical photograph
-Not essential but useful for recording before and after
treatment tissue appearance
-Can not always be relied on for comparing color changes
in gingiva but they depict gingival morphologic changes
30. Review of initial examination
If no emergency care is required the patient is
dismissed and instructed when to report for 2nd visit.
Before second visit, a correlated examination is made of
the radiographs and casts to relate the radiographic
changes to unfavorable condition represented on the
casts.
Casts should be checked for-Abnormal wear
-Plunger cusps or ridges
-Malposed teeth
-Cross bite.
Such areas are marked for future reference.
The radiographs and casts are valuable diagnostic aids.
However, clinical findings constitute the basis for
diagnosis.
31. Second visit
Clinical examination
Extra oral
Head and neck
Examined for
Facial asymmetries
Altered pigmentation or discoloration
Swellings
Abscess or draining sinuses
Ulcerations
Lymph node- Supra clavicular Palpated for
Acute infection
Chronic infection or distant metastasis -
Muscles of mastication and TMJ
32. Intra oral
Oral hygiene
The cleanliness of the oral cavity is appraised in term of
the extent of
Accumulated food debris
Materia alba
Tooth surface stains
Plaque - detected well by disclosing solutions.
- Quality rather than quantity decides
severity of periodontal destruction
33. Examination of teeth
–should note for
caries
developmental defects
wasting diseases of teeth
hypersensitivity
proximal contact relationship
34. Forms of wasting are;
Erosion (corrosion ) ;
A sharply defined wedge shaped depression in
the cervical area of the facial tooth surface
ABRASION :
Refers to loss of tooth substance induced by
mechanical wear other than
Attrition ; Occlusal wear resulting from
functional contacts with opposing
teeth.
ABFRACTION – pathological loss of hard tooth
substance by biomechanical loading forces
35. Dental Stains :
Pigmented deposits on the teeth. Carefully examined to
determine their origin.
Hypersensitivity :
Root surfaces exposed by gingival recession may be
hypersensitive to thermal changes/tactile stimulation located
by gentle exploration with a probe/cold air.
36. PROXIMAL CONTACT RELATIONS:
Slightly open contacts - permit food impaction.
Tightness of contacts - Checked by means of
clinical observation and with Dentalfloss
Abnormal contact relationships may also initiate
occlusal changes.
Such as:
Shift in the median line between incisors.
Labial version of the maxillary canine
Buccal/lingual displacement of the posterior
teeth
Uneven relationship of the marginal ridges
37. TOOTH MOBILITY:
All teeth have a slight degree of physiologic morbility.
Varies for different teeth and at different times of the
day. morning & progressively decrease ( no occlusal
contact during sleep.)
38. Tooth mobility occurs in 2 stages
The Initial/Intrasocket stage : Tooth moves within
the confines of theperiodontal ligament.
Associated with viscoelastic distortion of
theligament and redistribution of periodontal fluids,
interbundle contact,fibers.).
The secondary stage : Occurs gradually. Entails
elastic deformation of the alveolar bone in response
to increased horizontal forces..
39. GRADING OF MOBILITY :
Normal mobility'
Grade 1: Slightly more than normal
Grade II: Moderately more than normal
Grade III : Severe mobility facio lingually and/or mesio distally combined
with vertical displacement
Miller mobility index
The first distinguishable sign of movement greater than normal
(physiologic).
Movement of the tooth which allows the crown to move 1 mm from its
normal position in any direction.
Teeth which may be rotated or depressed in their alveoli.
Abnormal/Pathologic Mobility :
Mobility beyond the physiologic range "Loss of tooth Support" (Bone Loss)
can result in mobility.
"Trauma from occlusion" (Injury produced by excessive occlusal forces
incurved because of abnormal occlusal habits such as bruxism and
clenching is a common cause of tooth mobility :
40. Mobility : Also increased by hypofunction. Mobility produced by TFO
occurs initially as a result of resorption of cortical layer of bone
leading to reduced fiber support, and later as an adaptation
phenomenon resulting in a widened periodontal space.
Extension of inflammation from the gingiva/from the periapex into
the periodontal ligament -. Eg.Periapical abscess in the absence of
periodontal disease.
Periodontal surgery : Temporarily
Tooth mobility is increased in pregnancy.
Pathologic processes of the jaws that destroy the alveolar bone and
/or roots of the teeth. Eg. Osteomyelitis and tumours of the jaws.
41. ADVANCES
More precise and objective measurement of tooth mobility
has been pursued and includes mechanical, electronic and
optical devices, and laser Doppler vibrometry.
More recently, the Periotest® (Gulden-Medizintechnik,
Bensheim, Germany), a device resembling a dental
handpiece, has gained favor in evaluating and monitoring
tooth mobility and clinical success of dental implants.
42. TRAUMA FROM OCCLUSION:
Refers to injury produced by occlusal forces. Diagnosis
of TFO is made from the condition of the periodontal
tissues.
Periodontal findings suggesting the presence of TFO
include :
Excessive tooth mobility,
radiographic evidence of a widened periodontal space,
vertical/angular bone destruction,
infrabony pockets,
pathologic migration, especially of the anterior teeth
43. PATHOLOGIC MIGRATION OF THE TEETH:
Alterations in tooth position should be
carefully noted.
Premature tooth contacts in posterior
region that deflect the mandible
anteriorly contribute to
destruction of the periodontal of the
maxillary anterior teeth
pathologic migration, premolar of
anterior teeth in young person - sign of JP.
SENSITIVITY TO PERCUSSION:
Is a feature of inflammation of the periodontal tissues..
44. Excessive Overbite : Most frequently in the
anterior region may cause .Impingement of the
teeth on the gingiva, food impacation, gingival
inflammation, gingival enlargement and pocket
formation.Real Significance of excessive overbite
for gingival health is however, controversial.
Open bite Relationships :
Abnormal vertical spaces exist between the
maxillary and mandibular teeth.
Accumulation debris, calculus formation,
extrusion of teeth - result from reduced
mechanical cleansing by the passage of the food.
Most often occurs in anterior region. Posterior
open bite is occasionally seen.
45. CROSSBITE :
Normal relationship of the mandibular teeth to the maxillary teeth is
reversed. Maxillary teeth being lingual to the mandibular teeth.
Crossbite may be unilateral/bilateral.
CAUSES :
TFO, Food impaction, Spreading of the mandibular teeth, associated
gingival and periodontal disturbances.
Check for
Functional Occlusal Relationships :
Important part of the diagnostic procedure. Dentitions that appear
normal when the jaws are closed may present marked functional
abnormalities.
46. Mouth odors
Introduction
Also termed as fetor exore, fetor oris and oral
malodor, bad breath.
Common complained of adult population prevalence
may be as high as 50%, in most cases originate
from oral cavity.
●In many studies but not all, periodontal disease
related parameters have been found to be
associated with bad breath levels.
Definition
“It is foul or offensive odor emanating from the
oral cavity.”
First described by howe in 1874.
47. Etiology
Multifactorial etiology
1. Local factors of pathologic origin
- Poor oral hygiene
-Extensive caries
-Gingivitis and Periodontitis
-Open contact which allows food impaction
-Vincent’s disease
-Hairy or coated fissured tongue
-Dry socket
-Necrotic tissue from ulceration
-Cyst with fistula draining in oral cavity
2. Local factors of non pathologic origin
● In the morning due to lack of cheek and tongue movement,
● Smoking.
● denture traps food debris and causes denture breath.
48. Extraoral Sources of Mouth Odour
ENT
Bronchial and lung
Gastro intestinal tract
Liver-liver insufficiency(cirrhosis)-sweetish amine odour
Alcoholics- Alcoholic breath
Systemic metabolic disease-Diabetes- Acetone odor
Kidney dysfunction- Uremic breath
Halitosis due to xerostomia
Hormonal –increase in projestrone level during menstrual
cycle
Medications-metronidazole, antineoplastic agents
,diuretics,etc
Eucalyptus containing medication
Arsenic smells of rotten eggs
49. Pathogenesis
●The most common cause of mouth odor is being local
causes.
● Sulphur compounds such as indole, sketole & volatile
sulfur compounds hydrogen sulphide, methyl
mercapten and dimethyl sulphide
50. Diagnosis of halitosis through
Medical history
Clinical / laboratory examination
Self examination
Organoleptic rating
Specific character of breath odor
Portable volatile sulfide monitor
Gas chromatography
field or phase contrast microscopy
Saliva incubation test
Electronic nose
51. Quality and quantity of saliva
Protective and maintain oral soft tissue in a physiologic state
.
Plaque is mechanically cleansed by saliva from oral surfaces.
By buffering acids produced by bacteria.
Controlling bacterial activity.
Antibacterial factors
Salivary antibodies
Preponderant Ig A. (secretary)
Lesser amount Ig G and Ig M.
Salivary secretion decreases in certain conditions causing
xerostomia
Salivary secretion increases whenever local irritation in oral
cavity & in certain gingival disease states
52. Soft tissue examination
Floor of mouth
Oropharyngeal region
Tongue
Lips
Soft tissue should be examined for
-Keratotic or nonkeratotic white lesions
-Ulcerative lesions
-Vesiculobullous lesions
-Precancerous conditions and precancerous lesions.
Particularly in case of desquamative gingivitis, oral soft tissue
examination is very important.
Frenum
-High frenum attachment causes mucogingival problems.
-In case of upper labial frenum it can lead to midline diastema.
53. .
Plaque
“Soft deposit that form the biofilm adhering to the
tooth surface or other hard surfaces in the oral cavity
including fixed or removable prosthesis.”
Calculus
“It is a hard deposit that forms by mineralization of
dental plaque and is generally covered by a layer of
unmineralized plaque”.
54. PLAQUE AND CALCULUS :
Many methods for assessing plaque and calculus
accumulation.
Supragingival plaque and calculus
Directly observed
amount measured with a calibrated probe.
Sub gingival calculus :
Each tooth surface is carefully checked to the level of the gingival
attachment with a sharp no. #17or#3A explorer.
For Visualization of the Calculus :
Warm air may be used to deflect the gingiva
Radiographs :
May sometimes reveal heavy calculus deposits interproixmally and even
on the facial and lingual surfaces. But it cannot be relied for the
thorough detection of calculus.
55. Examination of periodontium
It is an important part of oral examination
Gingiva
Color
Generally described as coral pink, produced by
Vascular supply
Thickness and degree of keratinization
Presence of pigment containing cells.
56. Consistency
It is firm and resilient with the exception of the movable free margin,
tightly bound to underlying bone.
● In chronic gingivitis it may be destructive with edematous soft
consistency and reparative with fibrotic changes.
● In case of acute gingivitis diffuse puffiness, softening, eroded
surface and vesicle formation can be seen.
Contour and form
Depends on
-Shape of teeth.
-Alignment in the arch.
-Location & size of the area of proximal contact.
-Dimensions of facial & lingual embrasures.
● The marginal gingiva follows scalloped outline on the facial and
lingual surfaces.
Gingival contour changes with gingival enlargement such changes may
also occur in other conditions. e.g. Stillman’s cleft
Mc call’s festoons.
57. Size
Sum total of bulk of cellular & intercellular
elements and their vascular supply.
Alteration in size is a common feature of gingival
disease. Gingival enlargement can be classified as
Inflammatory enlargement
Drug induced enlargement
Enlargement associated with systemic diseases.
Conditioned enlargement
Non specific conditioned enlargement
Systemic diseases causing gingival enlargement
Neoplastic enlargement
False enlargement
58. Surface texture
orange peel.
● best viewed by drying the gingiva.
● Attached gingiva is stippled, marginal gingiva is not.
Varies among individuals and areas of mouth
● Varies with age.
Microscopically produced by alternate rounded protuberances and
depressions in the gingival surface. The papillary layer of connective tissue
projects into the elevations and the elevated & depressed areas covered
by epithelium.
● Loss of surface stippling is an early sign of gingivitis.
● In chronic inflammation the surface is either smooth & shiny or firm
& nodular, depending on whether the dominant changes are exudative or
fibrotic.
59. Position
Refers to the level at which the gingival margin
attached to the tooth.
● Actual position is the level of epithelial
attachment on the tooth.
● Apparent position is the level of the crest of
the gingival margin.
Classification of Recession
By Sullivan & Atkins
Four morphologic categories
shallow narrow
shallow wide
deep narrow
deep wide
60. By Miller
Class-I This includes marginal tissue recession that does not extend to
the mucogingival junction. There is no loss of bone or soft tissue
in the interdental area. This type of recession can be narrow or
wide.
Class-II Consists of marginal tissue recession that extends to or beyond
mucogingival junction. There is no loss of bone or soft tissue in
the interdental area. Sub classified into wide and narrow.
Class-III There is marginal tissue recession that extend to or beyond the
mucogingival junction in addition there is bone &/or soft tissue
loss interdentally or there is malpositioning of teeth.
Class-IV There is marginal tissue recession that extend to or beyond the
mucogingival junction with severe bone and soft tissue loss
interdentally &/or severe tooth malposition.
61. A frenum is a fold of mucous membrane,
usually with enclosed muscle fibers, that
attaches lips and cheeks to the alveolar mucosa
&/or gingiva and underlying periosteum.
Tension test
A frenum becomes problem if the attachment is too close
to the marginal gingiva. Tension on the frenum may pull
the gingival margin away from the tooth. This condition
may be conductive to plaque accumulation an inhibit
proper brushing of teeth.
62. Width of attached gingiva
“Distance between the mucogingival junction and the
projection on the external surface of the bottom of the
gingival sulcus or periodontal pocket.”
Greatest in incisors
Maxilla -3.5 to 4.5mm,
Mandible -3.3 to 3.9mm.
Least in first premolar
Maxilla -1.9mm,
Mandible -1.8mm.
Width of attached gingiva increases with age and in
supraerupted teeth.
63. Clefts
Stillman’s clefts are apostrophe shape indentations
extending from and into the gingival margin for varying
distances, generally present on facial surface may be 1 or 2
in relation with a single tooth.
The margins of the clefts are rolled underneath the linear
gap in the gingiva and the remainder of the gingival margin
is blunt instead of knife edged.
64. Periodontal pocket
It is a pathologically deepened gingival sulcus.
Classification
Gingival pocket- Pseudo pocket .
Periodontal pocket
Two types
Suprabony (Supracrestal /Supraalveolar)
Intrabony (Infrabony /Subcrestal or Intra alveolar)
the lateral pocket wall lies between the tooth surface and
alveolar bone.
According to involved tooth surfaces it may be classified as
Simple pocket
Compound pocket
Complex pocket
65. Signs -Color changes to bluish red
-Rolled edge of gingival margin
-Edematous gingiva
-Presence of bleeding
-Suppuration
-Loose extruded tooth.
Symptoms
- generally painless or localized or dull
radiating pain.
-sensation of pressure after eating.
-foul taste in localized area.
-sensitivity to hot and cold.
-toothache in absence of caries.
66. Detection of pockets
- The only accurate method of detecting and measuring
periodontal pockets is careful exploration with a periodontal
probe.
B L Philstrom has classified 3 generation of probes.
First generation-conventional probes
Second generation-probes with controlled force
application
Third generation-probes with controlled force, automated
measurement and computerized data capture.
-The periodontal pocket is a soft tissue change can not be
detected radiographically.
-Gutta purcha points or calibrated silver points can be used
with the radiograph to assist in determining the level of
periodontal pockets.
67. Pocket depth
The biologic depth is the distance between the gingival margin and the base of
the pocket, measured only in carefully prepared & adequately oriented
histologic sections.
The probing depth is the distance to which an ad hoc instrument (probe)
penetrates into the pocket.
Depth of penetration depends on
- Size of the probe
- Force with which it is introduced
- Direction of penetration
- Resistance of penetration
- Convexity of the crown.
The probing forces have been explored by several investigators, forces of
0.75N have been found to be well tolerated.
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.
Special attention should be directed to detecting the presence of interdental
craters and furcation involvement.
Naber’s probe is used specially for easier and more accurate exploration of
the horizontal component of furcation lesions.
68. Level of attachment versus pocket depth
Pocket depth
It is the distance between the base of pocket and the gingival
margin.
Level of attachment
The distance between the base of the pocket and the fix point
on the crown, such as cementoenamel junction.
It is a better indication because changes in the level of
attachment can only due to gain or loss of attachment and
periodontal destruction.
● Determining the level of attachment
-Gingival margin on anatomic crown
Level of attachment = pocket depth - distance from gingival
margin to C-Ejunction.
-Gingival margin coincides with C-E junction ,Loss of
attachment = pocket depth
-Gingival margin apical to C-E junction, Loss of attachment =
pocket depth + distance between the C-E junction
and gingival margin.
69. Advances in measurement of periodontal attachment loss
1)Tolerance method to determine thresholds for probing
measurements
This method uses two replicate measurements of each site which are
made for each subject. Their standard deviation is then calculated.. Thus
using this method any change below 3mm is considered to be unreliable
and this makes it possible to measure small changes of attachment using
manual probing.
2) Computer linked electronic constant pressure probes currently
available includes:
The Florida probe incorporates constant force, precise electronic
measurement and constant storage of data.
The Interprobe which has an optical encoder transduction element.
The Birek probe which works by constant air pressure and uses the
occlusal surface as its reference point .
The Jeffcoat probe automatically detects CEJ.
70. 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.
It is an earlier sign than color changes.
Depending on the severity of the inflammation bleeding can vary
from a tenuous red line along the gingival sulcus to profuse bleeding.
After successful treatment bleeding on probing ceases.
When to probe
For diagnosis
Monitoring course of treatment
Monitoring maintenance
Probing around implants
To prevent scratching of the implant surface, plastic probes
should be used instead of steel probes.
71. Clinical Indices in Dental Practice
•O.H.I.S(GREEN & VERMILLION 1964)
•PLAQUE CONTROL RECORD(O LEARY T.J.1972)
•GINGIVAL BLEEDING INDEX(AINAMO & BAY 1975)
•SULCUS BLEEDING INDEX (MUHELMAN & SON)
•GINGIVAL INDEX (LOE &SILLNESS 1963)
•PERIODONTAL INDEX (RUSSEL INDEX 1956)
72. Determination of disease activity
● Currently no sure method to determine disease activity.
Inactivate lesions may show little or no bleeding on probing &
minimal amount of gingival fluid, the bacterial flora revealed
by dark field microscopy consists of coccid cells.
● Active lesions bleed more readily on probing and have
large amounts of fluid & exudate, their bacterial flora shows a
greater no. of spirochetes & motile bacteria.
In patients with aggressive Periodontitis, progressing and non
progressing sites may show no differences in bleeding on
probing.
73. Alveolar bone loss
Evaluated by clinical and radiographic examination.
Probing is helpful for determining
The height and contour of the facial & lingual bones
obscured on the radiograph by the dense roots.
The architecture of the interdental bone.
Transgingival probing performed after the area is
anaesthetized, is a more accurate method of evaluation
and provides additional information on bone architecture.
74. Palpation
Palpating the oral mucosa in the lateral and apical
areas of the tooth may help to locate the origin of
radiating pain that the patient can not localize.
Infection deep in the periodontal tissues and the
early stages of a periodontal abscess may also be
detected by palpation.
75. Suppuration
The presence of abundant no. of neutrophils in the gingival
fluid transforms it into a purulent exudate.
It is not by itself a good indicator.
Clinically presence of pus 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.
The purulent exudate is formed in the inner pocket wall
and therefore the external appearance may give no indication
of its presence. Pus formation does not occur in all
periodontal pocket but digital pressure often reveals it in
pockets where its presence is not suspected
76. Acute periodontal abscesses
Gingival abscess
confined to marginal gingival tissues, often at previously non-diseased
sites..
offending foreign material is, thus, often diagnostic.
history of 1–2 days of pain and very localized gingival swelling
red, shiny swelling confined to marginal gingival tissues.
Pericoronal abscess
a partially erupted tooth can be detected clinically
abscess is present in the absence of any periodontal pocket on the vital
tooth or vital teeth adjacent to the partially erupted tooth.
Periodontal abscess
acute /chronic in nature.
Differential diagnoses for periodontal abscesses, when the clinical
presentation is of a painful, red swelling of periodontal tissues
Periapical abscess
It is usually collection of pus in the periapical area of the tooth which is
carious or nonvital.
77. Diagnosis Periodontal abscess
Careful probing with history,
clinical and radiographic findings.
Probing usually detects a channel
from the marginal area to the deeper
tissues.
Gingival
abscess
Usually by
history of
trauma and by
probing.
Probing detects
involvement of
gingival margin
and interdental
papilla.
Periapical
abscess
Early acute
periapical
abscess shows no
radiographic
changes.
Clinical features,
tooth with
extensive caries
or history of
trauma to tooth.
Pain on vertical
percussion.
78. The periodontal screening & recording system
(1) determine the periodontal health status of the
patient
(2) identify patients needing a comprehensive
periodontal assessment.
for the detection of periodontal disease recommended by
both the ADA and the AAP ( 1992)
Easier & faster screening and recording of the
periodontal status of a patient by a general practitioner
or a dental hygienist.
It uses a specifically designed probe that has a 0.5mm
ball tip is color coded from 3.5 to 5.5mm.
The patient’s mouth is divided into six sextant. Each
tooth is examined at six points.
The deepest finding is recorded in each sextant along
with other findings,
Codes 0-5,are alloted on the visibility of color band
79. Sub-Gingival Temperature
The thermal probes are sensitive diagnostic devices for measuring early
inflammatory changes in the gingival tissues.
One commercially available system, the PerioTemp probe
enables the calculation of the temperature differential between the
probed pocket and the subgingival temperature .
Studies have demonstrated that
the subgingival temperature at diseased sites >healthy sites
natural antero-posterior temperature gradient exists within the dental
arches (posterior sites warmer than anterior sites).
mandibular sites were reported to be warmer than maxilliary sites.
80. OCCLUSAL ANALYSIS, DIAGNOSIS AND MANAGEMENT IN THE
PRACTICE OF PERIODONTICS
Occlusal trauma– Injury resulting in tissue changes within the
attachment apparatus as a result of occlusal force (s).
Primary occlusal trauma– Injury resulting in tissue changes
from excessive occlusal forces applied to a tooth or teeth
with normal support. It occurs in the presence of: 1) normal
bone levels, 2) normal attachment levels, and 3) excessive
occlusal force (s).
Secondary occlusal trauma– Injury resulting in tissue changes
from normal or excessive occlusal forces applied to a tooth or
teeth with reduced support . It occurs in the presence of: 1)
bone loss, 2) attachment loss, and 3) normal/excessive occlusal
force (s).
81. Clinical indicators of occlusal trauma
Fremitus
Mobility(progressive)
Occlusal discrepancies
Wear facets in presence of other indicators
Tooth migration
Fractured tooth or teeth
Thermal sensitivity
82. MICROBIOLOGICAL DIAGNOSTIC
TESTING IN THE TREATMENT OF
PERIODONTAL DISEASES
Microbiological tests for plaque samples
Microscopic identification
Microbiological culturing
Enzymatic assays
Immunoassays
Nucleic acid probes
Polymerase chain reaction assays
Commercial diagnostic kits
Evalusite
Omnigene
Perioscan
83. Main advantages of periodontal diagnostic test systems using bacterial
markers
Some appear to be predictive of disease activity in longtidunal studies
Simple to use
Results of chairside test kits available in short time
Chairside test kits produce visual results which can be shown to the
patient
Main disadvantages of periodontal diagnostic test systems using bacterial
markers
Polymicrobial nature of the disease
Most are not predictive of disease activity
The site to sample needs to be known
Detection of bacteria only being searched for
Some are sent away to a special laboratory
Expensive
84. ANALYSIS OF HOST RESPONSES AND RISK
FOR DISEASE PROGRESSION
Salivary enzymes derived from oral microorganisms and
polymorphonuclear leukocytes
Systemic conditions affecting salivary enzymes
Salivary and serum immunoglobulins as potential diagnostic
markers for periodontitis
Intrinsic neutrophil defects that might serve as markers for
increased susceptibility to periodontitis
Some of the acquired neutrophil defects that might serve as
markers for increased susceptibility to periodontitis
85. ANALYSIS OF GINGIVAL CREVICE FLUID AND RISK OF
PROGRESSION OF PERIODONTITIS
Gingival crevice fluid (GCF) is an inflammatory exudate that
seeps into gingival crevices or periodontal pockets around teeth
with inflamed gingiva.
Over 65 GCF components have been preliminarily examined as
possible markers for the progression of periodontitis. These
components fall into three general categories:
host-derived enzymes and their inhibitors
inflammatory mediators and host-response modifiers
tissue-breakdown products
1)Periogard AST in GCF
2)Periocheck(ACTech)
3)Prognostik
86. LABORATORY TESTING OF PATIENTS WITH
SYSTEMIC CONDITIONS IN PERIODONTAL
PRACTICE
In addition to the diagnosis, laboratory tests are
also extremely important in assisting in the
management of the patient during treatment of
the disease
87. DIAGNOSIS OF ACUTE PERIODONTAL LESIONS
I - Necrotizing ulcerative gingivitis (NUG)
Diagnostic essentials for NUG
1.Lesions are painful
2.Lesions are gingival ulcers, punched-out crater-like, of interdental
papilla and may involve marginal gingiva
3.Gingival ulcers bleed spontaneously or readily
Non-essential clinical features of NUG, the absence of which does not
preclude the diagnosis of NUG
1."Pseudomembrane" of sloughed necrotic debris and bacteria covering
the ulcerated area
2.Foetor ex ore (foetor oris, fetid breath)
3.Fever, malaise
4.Lymphadenopathy – submandibular (and cervical)
II - Necrotizing ulcerative periodontitis (NUP)
Diagnostic clinical features of NUP
1.Deep interproximal craters with denudation of interdental alveolar bone
2.Sequestration of interdental, and possibly buccal and/or lingual, alveolar
bone
88. Conditions that may include gingival ulceration as
a clinical feature. The gingival ulceration,
however, is not characteristic of NUG/NUP
Viral infections
Bacterial infections
Mucocutaneous conditions
Traumatic conditions
89. SYSTEMIC RISK FACTORS
Diabetes and glycemic control
HIV infection
Osteoporosis
Familial and genetic risk factors
Psychological factors
Aging
90. CONCLUSION:
However, as periodontal disease is site specific and its
progression may be episodic it is difficult to determine
which sites to test, when to test them. Thus a sound clinical
judgment is a must for diagnosis. Hence diagnostic
procedures must be systematic and organized for specific
purposes.
91. REFERENCES:
Clinical Periodontology by Carranza and Newman, 10th
Edition
Text Book of Clinical Periodontology by Jan Lindhe
Periodontics by Grant Sten, Listgarten, 6th Edition.
Contemporary Periodontics by Goldman, 6th Edition
Periodontology 2000. 2004; 34
Rose Mealey Periodontics - Medicine, Surgery &
Implants.
Br Dent J. 1998; 184
Wilson and Kornman. Periodontics
Clinical practice of the dental hygienist ,9 th edition by
Esther M . Wilkins
93. Curved #2 Nabers probe with color
Coded markings from 3,6,9,12mm
94. Bite wing radiographs
The most accurate radiographic projection of the alveolar
bone level
posterior maxillary periapical radiographs are expected
to produce a more distorted view of the buccal and lingual
periodontal bone levels.
U/L arch – alveolar bone level can be compared in one
image
95. Tuned aperture computed tomography (TACT®)
Assessment of dentoalveolar tissues in three
dimensions
The motivation behind the development of TACT®
was to be able to achieve this with existing dental
equipment and without the high cost and dose
associated with computed tomography
TACT® was shown to improve the ability of observers
to detect osseous defects around implants
The feasibility of using TACT® as an alternative for
preoperative imaging of the implant site has also been
investigated
96. Transgingival probing or sounding
Done under local anesthesia
Confirms the the extent and configuration of
the intrabony component of the pocket & of
furcation defects
Extremely useful just before flap reflection
Blind procedure but better than probing alone ,
as we can be aware of situation before flap
reflection – larger exostoses, ledges , troughs ,
craters , vertical defects or combinations of
these defects
97. Method
Anesthetize the tissue locally
The probe is walked along the tissue tooth interface so
as to feel the bony topography
The probe may also be passed hoizontally through the
tissue to provide three dimensional information regarding
bony contours – thickness, height, & shape of the
underlying base
98. EFFICACY OF DIAGNOSTIC TESTS
There are a few principal concepts that must be
under stood by practitioners when they use diagnostic
tests. The most basic of these concepts are:
1. Gold standard
2. Accuracy
3. Sensitivity
4. Specificity
5. Positive predictive value
6. Negative predictive value
99. a gold standard measure is obtained from an
independent definitive diagnosis of disease
presence or absence, which is usually provided
by histopathologic examination of the tissues.
The basic method used to compare the
diagnostic test with the gold standard is
the decision matrix.
100. DECISION MATRIX - GOLD STANDARD
Test
Result
Disease Present Disease Absent Total
(D+) (D-)
Positive
(T+)
Negative
(T-)
TP FP TP+FP
FN TN FN+TN
Total TP+FN FP+TN
Here test results (test positive and test negative) tells
us whether disease is truly present or absent.
This is called the accuracy of the test and is calculated
as TP + TN/all tests conducted, i.e., the proportion or
percentage of times that the test gives accurate
results.
101. Sensitivity
(the true-positive ratio)
TP/TP+FN.
represents the proportion or percent¬age of times that the tests
results help correctly identify patients with disease.
Specificity
(the true-negative ratio)
TN/FP + TN.
the propor¬tion of patients who do not have Periodontal disease
that has been correctly identified with the test results.
specificity represents the proportion or percentage of times that the
test results help correctly identify patients who do not have disease.
102. The decision matrix in a horizontal dimension, calculate two types of
predictive values.
Positive predictive value
TP/TP + FP
The proportion or percentage of true-positive results of all positive
results.
In other words, when the test result is positive, what is the prob¬ability
that the patient (or site) really has disease?
Negative predictive value
TN/FN + TN
The proportion or % of true-negative test results of all negative test
results.
That is what percent do not have the disease
103. It is important to understand that both the positive
predictive value and the negative predictive value are
affected by disease prevalence in the population being
tested
Diagnostic testing should be considered an aid to the
diagnostic process—not a device or procedure that provides
the diagnosis.
104. Threshold for Disease
When do we actually label the process being observed as
Periodontal disease?
Unfortunately, in many patients there is no clear
demarcation between disease and no disease.
Periodontal disease presents throughout a range from
incipient to severe.
Hence it may be reasonable for practitioners to consider
more than one threshold of disease at which the test result
is determined to be positive to get a sense of the magnitude
of risk taken when making this decision one way or the other.
105. Probes and the examination of
patients considered for implants
Examination of patients - considered for implants includes
both clinical evaluation of soft tissues and a radiographic
evaluation..
Probing around implants is difficult
(1) the prosthetic construction may need to be removed
for access
(2) standard metal instruments are unsuitable.
Instead, plastic or titanium probe tips should be used to avoid
damage of the implant / tissue interface. If automatic probing
is considered, the Florida Probe is available with a titanium tip
that will not hurt the implant ; also, the Interprobe system
comes with disposable plastic tips.
106. Clinical evaluation of dental implant treatment
Diagnostic procedure prior to implant placement
Competent treatment planning is a key to long term success of
implant therapy. Indications & contraindications must carefully
be balanced & optional treatments must be taken into the
decision making process in each individual patient eligible for
implant therapy
2. Diagnosis
3. Medical history
107. 4. Dental history-
5. Intra / Extra Oral examination
Oral hygiene
Parafunctional activities eg bruxism
Salivary flow
Soft tissue condition eg erosive , bullous or hyperkeratotic lesion
Periodontal health
6. Study casts
7. Anatomical limits for fixture placement
8. Radiographic examination
Periapical radiographs
Orthopantomographs
Computed tomogram
Combination . etc
9. Fabrication of radiographic splint
10. Additional bone evaluation
11. Designs for dentulous/ edentulous patient treatment
12. Consultation
108. Diagnostic procedure between implant placement and
initiation of prosthesis fabrication & maintenance
Evaluation during the phase of tissue integration
Measurement of insertion torque as well as assessments of bone implant
damping reactions (e.g. damping & resonance frequency analysis) are used to
determine the initial stability of the newly placed implants.
•Periotest-
•Resonance frequency analysis (RFA)- method based on steady state ,
swept frequency technique – non invasive , easy to use & capable of
eliciting quantitative information on implant stability & stiffness
Soft tissue integration –BOP , Suppuration, probing depth
Radiographs
For correct placement of implant
Position , sink depth , & angulation
Healing – 6 weeks-12 months
109. Conclusion:
the most valuable clinical parameter for the
assessment of the health status of the peri
implant tissues are the presence or absence of
mucosal inflammation, signs of infection & probing
depth
Standardized r/g at regular intervals- to assess
the bone implant relationship over time
