This document provides information on periodontal examination including medical history, extraoral examination, temporomandibular joint examination, examination of the gingiva and periodontium, signs of gingival disease, probing depth, bleeding on probing, gingival color changes, consistency changes, surface texture changes, contour changes, size changes, position changes, recession, papilla changes, mobility, periodontal pockets, plaque, periodontal diseases, chronic periodontitis features, aggressive periodontitis features, gingivitis classification, and periodontitis classification. Key aspects covered are signs of gingival disease, classification of gingivitis and periodontitis, features of chronic and aggressive periodontitis.

1. Periodontal Examination:
Diagnosis, prognosis and treatment plan

2. MEDICAL HISTORY:

4. Extraoral Examination:
‫سر‬/‫صورت‬ ‫گردن‬
‫زخم‬ ‫وجود‬
‫آبسه‬ ‫وجود‬
‫رنگ‬ ‫تغییرات‬
‫تورم‬ ‫وجود‬
‫قرینگی‬ ‫عدم‬

9. Examination of the temporomandibular joint.
Have the patient open and close slowly.

13. The gingiva
The Tooth-Supporting
Structures
1-periodontal ligament
2-alveolar bone
3-cementum
periodontium
Healthy Periodontium

14. Normal feature of Gingiva

15. 15
Mucogingival junction
alveolar mucosa
Gingival sulcus
knife edge

16. 7
Variability of gingival width

18. •The depth of this sulcus, as determined in
histologic sections, has been reported as 1.8 mm.
•Probing depth of a clinically normal gingival
sulcus in is 2 to 3 mm.

20. Vestibular Depth:

21. Sign :
‫لثه‬ ‫شیار‬ ‫از‬ ‫خونریزی‬
‫لثه‬ ‫تغییررنگ‬
‫لثه‬ ‫بافتی‬ ‫سطح‬ ‫تغییر‬
‫لثه‬ ‫قوام‬ ‫تغییر‬
‫لثه‬ ‫وکانتور‬ ‫شکل‬ ‫تغییر‬
‫لثه‬ ‫موقعیت‬ ‫تغییر‬
‫اکلوزیون‬ ‫خوردن‬ ‫وبهم‬ ‫دندانها‬ ‫موقعیت‬ ‫تغییر‬
‫لثه‬ ‫شیار‬ ‫از‬ ‫چرک‬ ‫خروج‬
‫دهان‬ ‫ومزه‬ ‫طعم‬ ‫تغییر‬
‫پریودنتال‬ ‫های‬ ‫آبسه‬ ‫تشکیل‬
‫لثـــــه‬ ‫حــجم‬ ‫تـغیــیــر‬
‫وکـاذب‬ ‫حقیقی‬ ‫های‬ ‫پاکت‬ ‫تشکیل‬
‫فــورکـــــا‬ ‫درگــیری‬
‫؛بخاطر‬ ‫دنــــــــــــــــــدان‬ ‫لــــــقـــــــــــــــــــی‬...
، ‫شیرینی‬ ، ‫حرارتی‬ ‫تغییرات‬ ‫به‬ ‫دندانها‬ ‫بودن‬ ‫حساس‬

22. Bleeding on probing:

27. Color of Gingiva :

28. Color change in Gingiva
Bismuth line

30. Changes in the Consistency
In Gingival Disease
 Both chronic and acute inflammations produce changes
int the normal firm and resilient consistency of the
gingiva.
 Chronic gingivitis = edematous – (destructive) ,
fibrotic –(repairative) changes coexist
 The consistency of the gingiva is determined by their
relative predominance.

31. Change in Consistency :
spongy

32. Spongy Tissue

33. Fibrosis of the Gingiva

34. Surface Texture Changes in Disease
 The surface of normal gingiva usually
exhibits numerous small depressions
and elevations = stippling
 In chronic inflammation the surface
is either smooth and shiny or firm
and nodular
This depends on whether the dominant
changes are exudative or fibrotic

35. Smooth, Shiny Tissue
 Can be:
 exudative
Epithelial atrophy in atrophic gingivitis
Chronic desquamative gingivitis can also have
peeling of the surface

36. Smooth, Shiny Tissue

37. Surface Texture:

38. Countor :

39. Size of Gingiva:
Gingival Enlargement

40. Position:
Gingival recession

41. Gingival recession:

42. Cause of recession:
gingival abration(‫غلط‬ ‫زدن‬ ‫مسواک‬)
Malposition،‫دندان‬
،‫لثه‬ ‫التهاب‬
،‫اضافي‬ ‫فرنوم‬
overbite، ‫شدید‬،‫ارتودنسي‬ ‫دستگاههاي‬ ‫فشار‬
‫غلط‬ ‫پارسیل‬ ‫هاي‬ ‫پالك‬،
overhang‫پركردگي‬ ‫بودن‬،
‫لثه‬ ‫لبه‬ ‫با‬ ‫كراون‬ ‫مارجین‬ ‫غلط‬ ‫رابطه‬.
‫حرارتي‬ ‫تغییرات‬ ‫به‬ ‫حساس‬ ‫مربوطه‬ ‫دندان‬ ‫موارد‬ ‫این‬ ‫در‬ ‫اغلب‬،PH‫و‬
‫میباشند‬ ‫فیزیكي‬ ‫تماس‬.

43. Gingival Recession:
‫میگردد‬ ‫لثه‬ ‫تحلیل‬ ‫موجب‬ ‫پریودنتال‬ ‫سیربیماریهاي‬.
‫شیمیایي‬ ‫عوامل‬ ‫گاه‬(‫اكسیژنه‬ ‫،آب‬ ‫فنل‬ ، ‫نقره‬ ‫نیترات‬ ،‫آسپرین‬)
‫فیزیكال‬ ‫علل‬ ‫یا‬ ‫و‬(‫لثه‬ ‫بر‬ ‫لب‬ ،‫گونه‬ ،‫زبان‬ ‫فشار‬)
‫حرارتي‬ ‫گاه‬ ‫و‬(‫داغ‬ ‫غذاي‬ ‫و‬ ‫نوشیدني‬)‫ل‬ ‫تحلیل‬ ‫موجب‬ ‫توانند‬ ‫مي‬ ‫نیز‬‫ثه‬
‫گردد‬.
‫نكر‬ ‫خاتمه‬ ‫در‬ ‫و‬ ‫اپیتلیوم‬ ‫در‬ ‫اولسر‬ ‫موجب‬ ‫ابتدا‬‫آن‬ ‫وز‬
‫میشود‬.

44. Frenum:

45. Papilla :
Blunt

46. Missing and Blunted Papilla

47. Bulbous Papilla

48. Pathologic Migration:
‫اکلوزیون‬ ‫خوردن‬ ‫وبهم‬ ‫دندانها‬ ‫موقعیت‬ ‫تغییر‬

49. Pus:

50. Periodontal Abscess:

51. Mobility :

52. Periodontal Pocket:

53. Periodontal Pocket:

54. Disclosing Dental Plaque:

56. Plaque index:
number of collocated surface ×110
number of examined teeth ×4
Plaque index =
‫خوب‬30%-
‫متوسط‬30%‫تا‬70%
‫بد‬70%‫تا‬100%

57. Periodontal Diseases:
Extension of inflammation gingiva in
the supporting periodontal tissue
‫مزمن‬ ‫پریودنتیت‬:‫میزان‬ ‫؛‬ ‫ندارد‬ ‫وژنتیك‬ ‫ارثي‬ ‫زمینه‬
‫وجود‬ ‫همخواني‬ ‫انساج‬ ‫تخریب‬ ‫مقدار‬ ‫با‬ ‫موضعي‬ ‫محركهاي‬
‫سن‬ ‫ودر‬ ‫بالغین‬ ‫افراد‬ ‫در‬ ‫بیشتر‬ ‫؛‬ ‫دارد‬35‫مشاهده‬ ‫باال‬ ‫به‬
‫است‬ ‫ومزمن‬ ‫کند‬ ‫بیماری‬ ‫وسیر‬ ‫میشود‬

58. Chronic Periodontitis:
General clinical Features:
Pocket Formation with variable depth
Bleeding upon probing

59. Clinical features of
periodontitis:

62. Symptoms:
 Because chronic periodontatitis is usually
painless , patients may less likely to seek
treatment and accept treatment
recommendations.
 Occasionally ,pain may be present in the
absence of caries due to exposed roots that
an sensitive to heat ,cold ,or both.
 The presence of areas of food impaction
may add to the patients discomfort.

66. CEJ-GM= - 3 PD = 6 CAL = 3
CEJ-GM= 0 PD = 6 CAL = 6
CEJ-GM= 3 PD =6 CAL = 9

68. CEJ-GM= - 3 PD = 6 CAL = 3
CEJ-GM= 0 PD = 6 CAL = 6
CEJ-GM= 3 PD =6 CAL = 9

71. Radiography :

72. RADIOGRAPHIC ASSESMENT
PDs: widening
‫بودن‬ ‫متقطع‬ ‫یا‬ ‫نازک‬Lamina Dura:
Short roots:
Root resorption:
Crown / root: Clinical 1/1….1/2….1/3
Furcation involvement:
Horizontal bone loss:
Vertical bone loss:
Length of root Anatomy

73. Lamina Dura (LD):Radiopaque line
Periodontal Ligament Space (PDS): Radiolucent Line

77. ‫ژنژیویت‬
‫بندی‬ ‫تقسیم‬ ‫؛‬ ‫ژنژیویت‬
‫براساس‬:‫توزیع‬-‫آناتومی‬-
‫بیماری‬ ‫سیر‬
Localized
Generalized
Diffuse Marginal
papillary
Acute Chronic

79. Acute Gingivitis
 Sudden Onset
 Short Duration
 Painful

80. Localized Defuse:

81. Generalized Marginal with
localized defuse

82. Generalized Defuse Gingivitis

83. ‫پریودنتیت‬:‫براساس‬ ‫بندی‬ ‫تقسیم‬:‫توزیع‬–‫ماهیت‬–‫شدت‬.
Localized Generalized
Aggressive Chronic &.&.&.&
Mild moderate severe

84. Periodontitis
* Chronic periodontitis
* Aggressive periodontitis
* Periodontitis as a manifestation of
systemic diseases

85. Chronic periodontitis
may be further subdassified into
localized and generalized forms and characterized as
slight, moderate, or severe
……… following specific features:
• Localized form : < 3 0 % of sites involved.
• Generalized form:> 3 0 % of sites involved.
• Slight: 1 to 2 mm of clinical attachment loss.
• Moderate :3 to 4 mm of clinical attachment loss.
• Severe: >5 mm of clinical attachment loss.

86. Aggressive periodontitis

87.  Localized aggressive periodontitis (Ljp)
 Generalized aggressive periodontitis (Gjp)
‫موضعي‬ ‫نوع‬‫و‬ ‫آغاز‬ ‫بلوغ‬ ‫سن‬ ‫حدود‬ ‫در‬ ‫جواني‬ ‫سنین‬ ‫در‬ ‫بیماري‬
‫ب‬‫ه‬‫مولر‬ ‫دندانهاي‬ ‫اطراف‬ ‫در‬ ‫خصوص‬ ‫به‬ ‫استخوان‬ ‫تحلیل‬ ‫صورت‬
‫شود‬‫مي‬ ‫مشاهده‬ ‫وانسیزور‬.
‫ژنرالیزه‬ ‫نوع‬‫معموال‬ ‫بیماري‬ ‫این‬"‫زیر‬ ‫افراد‬ ‫در‬30‫سال‬(‫در‬ ‫گاهي‬
‫باالتر‬ ‫سن‬)‫گردد‬‫مي‬ ‫مشاهده‬.‫پریودنتال‬ ‫چسبندگي‬ ‫رفتن‬ ‫دست‬ ‫از‬‫عالوه‬
‫دائمي‬ ‫دیگر‬ ‫دندان‬ ‫سه‬ ‫در‬ ‫حداقل‬ ،‫دائمي‬ ‫اول‬ ‫مولرهاي‬ ‫و‬ ‫انسیزورها‬ ‫بر‬
‫شود‬‫مي‬ ‫دیده‬ ‫نیز‬(‫از‬ ‫بیش‬14‫باشد‬‫مي‬ ‫درگیر‬ ‫دندان‬)‫ارثي‬ ‫زمینه‬
‫انساج‬ ‫تخریب‬ ‫مقدار‬ ‫با‬ ‫موضعي‬ ‫محركهاي‬ ‫میزان‬ ‫؛‬ ‫دارد‬ ‫وژنتیك‬
‫نظیر‬ ‫خاص‬ ‫میكروبهاي‬ ‫؛‬ ‫ندارد‬ ‫همخواني‬:Porphyromonas
Gingivalis . &Aa‫دارد‬

88. Aggressive periodontitis classified into
Localized form
• Circumpubertal onset of disease.
• Localized (first molar) or incisor disease with
proximal attachment loss on at
least two permanent teeth, one of which is a
first molar.
• Robust serum antibody response to infecting
agents.

89. Generalized form
• Usually affecting persons under 30 years of
age (however may be older).
• Generalized proximal attachment loss
affecting at least three teeth other than first
molars and incisors.
• Pronounced episodic nature of periodontal
destruction.
• Poor serum antibody response to infecting
agents.

90. PROGNOSIS

91. Individual PrognosisIndividual PrognosisOVERALL PROGNOSISOVERALL PROGNOSIS
‫دندان‬ ‫لقی‬‫دندان‬ ‫لقی‬‫بیماری‬ ‫نوع‬:‫نوع‬Aggressive‫یا‬Chronic‫است‬
‫بیماری‬ ‫شدت‬{‫خفیف‬–‫متوسط‬–‫شدید‬}
‫استخوان‬ ‫تحلیل‬‫استخوان‬ ‫تحلیل‬‫اکلوژن‬ ‫مال‬‫اکلوژن‬ ‫مال‬
‫فورکا‬ ‫مشکالت‬‫فورکا‬ ‫مشکالت‬‫و‬ ‫مانده‬ ‫باقی‬ ‫استخوان‬ ‫میزان‬ ‫گرفتن‬ ‫نظر‬ ‫در‬ ‫با‬ ‫سن‬‫و‬ ‫مانده‬ ‫باقی‬ ‫استخوان‬ ‫میزان‬ ‫گرفتن‬ ‫نظر‬ ‫در‬ ‫با‬ ‫سن‬ALAL
‫خوردن‬ ‫وبهم‬ ‫بزرگ‬ ‫تاج‬ ‫با‬ ‫ومخروطی‬ ‫کوتاه‬ ‫های‬ ‫ریشه‬‫خوردن‬ ‫وبهم‬ ‫بزرگ‬ ‫تاج‬ ‫با‬ ‫ومخروطی‬ ‫کوتاه‬ ‫های‬ ‫ریشه‬
‫نسبت‬‫نسبت‬C/RC/R
‫وحضوریا‬ ‫بهداشتی‬ ‫دستورات‬ ‫اجرای‬ ‫در‬ ‫بیمار‬ ‫همکاری‬‫وحضوریا‬ ‫بهداشتی‬ ‫دستورات‬ ‫اجرای‬ ‫در‬ ‫بیمار‬ ‫همکاری‬
‫درمان‬ ‫نگهدانده‬ ‫فاز‬ ‫در‬ ‫وی‬ ‫منظم‬ ‫حضور‬ ‫عدم‬‫درمان‬ ‫نگهدانده‬ ‫فاز‬ ‫در‬ ‫وی‬ ‫منظم‬ ‫حضور‬ ‫عدم‬
‫دندان‬Restorativable‫ژنتیکی‬ ‫وبیماریهای‬ ‫ارث‬‫ژنتیکی‬ ‫وبیماریهای‬ ‫ارث‬
‫پاکت‬ ‫عمق‬‫پاکت‬ ‫عمق‬‫سیستمیک‬ ‫وحالتهای‬ ‫بیماریها‬‫سیستمیک‬ ‫وحالتهای‬ ‫بیماریها‬{{‫دیابت‬ ‫؛‬ ‫هورمونی‬ ‫تغییرات‬ ‫همچون‬‫دیابت‬ ‫؛‬ ‫هورمونی‬ ‫تغییرات‬ ‫همچون‬
‫خونی‬ ‫بیماریهای‬ ‫؛‬‫خونی‬ ‫بیماریهای‬ ‫؛‬}}
‫موکوژنژوال‬ ‫مشکالت‬{‫از‬ ‫پروب‬ ‫شدن‬ ‫رد‬MGL}((‫میزان‬‫میزان‬‫استخوان‬ ‫تحلیل‬‫استخوان‬ ‫تحلیل‬{{‫کم‬‫کم‬––‫متوسط‬‫متوسط‬––‫زیاد‬‫زیاد‬}}‫؛‬‫؛‬‫تحلیل‬ ‫نوع‬‫تحلیل‬ ‫نوع‬
––‫یا‬ ‫افقی‬‫یا‬ ‫افقی‬[[‫عمودی‬‫عمودی‬::‫دیواره‬ ‫چند‬‫دیواره‬ ‫چند‬112233‫باریک‬ ‫یا‬ ‫عمیق‬ ‫؛‬‫باریک‬ ‫یا‬ ‫عمیق‬ ‫؛‬]]
‫مانده‬ ‫باقی‬ ‫استخوان‬ ‫مقدار‬‫مانده‬ ‫باقی‬ ‫استخوان‬ ‫مقدار‬{{‫خفیف‬‫خفیف‬––‫متوسط‬‫متوسط‬––‫شدید‬‫شدید‬}}))‫؛‬‫؛‬
‫سیگارکشی‬‫دن‬
‫وسیع‬ ‫های‬ ‫وپرکردگی‬ ‫پوسیدگی‬
‫مناسب‬ ‫ونا‬ ‫لثه‬ ‫زیر‬ ‫رستورتیوهای‬
‫موضعی‬ ‫فاکتورهای‬ ‫وجود‬...‫و‬ ‫دندانی‬ ‫وجرم‬ ‫پالک‬
‫اندازد‬ ‫می‬ ‫تاخیر‬ ‫به‬ ‫را‬ ‫وترمیم‬ ‫زیاد‬ ‫را‬ ‫انساج‬ ‫تخریب‬ ‫میزان‬

92. prognosisprognosis
‫وضعیت‬‫وضعیت‬
‫أستخوان‬‫أستخوان‬
‫همكاري‬‫همكاري‬
‫بیمار‬‫بیمار‬((‫بهداشت‬‫بهداشت‬
‫و‬‫و‬recallrecall
‫فاکتورهای‬‫فاکتورهای‬
‫یا‬ ‫محیطی‬‫یا‬ ‫محیطی‬
‫سیستمیک‬‫سیستمیک‬
‫فوركا‬ ‫درگیري‬‫فوركا‬ ‫درگیري‬‫دندان‬ ‫لقي‬‫دندان‬ ‫لقي‬‫قابل‬ ‫نواحي‬‫قابل‬ ‫نواحي‬
‫نگهداري‬‫نگهداري‬
ExcellentExcellent--
‫قطعی‬‫قطعی‬
‫استخوان‬ ‫تحلیل‬‫استخوان‬ ‫تحلیل‬
‫ندارد‬‫ندارد‬
‫خوب‬ ‫خیلی‬‫خوب‬ ‫خیلی‬‫ندارد‬ ‫وجود‬‫ندارد‬ ‫وجود‬‫ندارد‬ ‫وجود‬‫ندارد‬ ‫وجود‬‫ندارد‬ ‫وجود‬‫ندارد‬ ‫وجود‬‫لثه‬ ‫وضعیت‬‫لثه‬ ‫وضعیت‬
‫حفظ‬ ‫وقابل‬ ‫عالي‬‫حفظ‬ ‫وقابل‬ ‫عالي‬
‫است‬‫است‬
GoodGood
‫قطعی‬‫قطعی‬
‫هست‬ ‫تحلیل‬‫هست‬ ‫تحلیل‬
‫سپورت‬ ‫ولي‬‫سپورت‬ ‫ولي‬
‫استخواني‬‫استخواني‬
‫است‬ ‫مناسب‬‫است‬ ‫مناسب‬
‫خوب‬‫خوب‬‫یا‬ ‫ندارد‬ ‫وجود‬‫یا‬ ‫ندارد‬ ‫وجود‬
‫شده‬ ‫کنترل‬‫شده‬ ‫کنترل‬
‫ندارد‬ ‫وجود‬‫ندارد‬ ‫وجود‬‫ندارد‬ ‫وجود‬‫ندارد‬ ‫وجود‬‫امكان‬ ‫راحتی‬ ‫به‬‫امكان‬ ‫راحتی‬ ‫به‬
‫كافي‬ ‫دسترسی‬‫كافي‬ ‫دسترسی‬
‫كنترل‬ ‫براي‬‫كنترل‬ ‫براي‬
‫فاکتورهای‬‫فاکتورهای‬
‫مسبب‬‫مسبب‬
FairFair
‫مؤقت‬‫مؤقت‬
‫هست‬ ‫تحلیل‬‫هست‬ ‫تحلیل‬
‫استخوان‬ ‫ولي‬‫استخوان‬ ‫ولي‬
‫باقیمانده‬‫باقیمانده‬
‫نیست‬ ‫مناسب‬‫نیست‬ ‫مناسب‬
‫نیست‬ ‫بد‬‫نیست‬ ‫بد‬‫کم‬ ‫دارد‬ ‫وجود‬‫کم‬ ‫دارد‬ ‫وجود‬‫درجه‬ ‫دارد‬ ‫وجود‬‫درجه‬ ‫دارد‬ ‫وجود‬
ll
‫دارد‬ ‫وجود‬‫دارد‬ ‫وجود‬‫قبول‬ ‫قابل‬‫قبول‬ ‫قابل‬
PoorPoor
‫مؤقت‬‫مؤقت‬
‫هست‬ ‫تحلیل‬‫هست‬ ‫تحلیل‬
‫تا‬ ‫متوسط‬‫تا‬ ‫متوسط‬
‫پیشرفته‬‫پیشرفته‬
‫ضعیف‬‫ضعیف‬‫دارد‬ ‫وجود‬‫دارد‬ ‫وجود‬
‫بیشتر‬‫بیشتر‬
‫دارد‬ ‫وجود‬‫دارد‬ ‫وجود‬
‫درجه‬‫درجه‬ll‫و‬‫و‬llll
‫دارد‬ ‫وجود‬‫دارد‬ ‫وجود‬‫امكان‬ ‫سختی‬ ‫به‬‫امكان‬ ‫سختی‬ ‫به‬
‫كنترل‬ ‫براي‬ ‫كافي‬‫كنترل‬ ‫براي‬ ‫كافي‬
‫فاکتورهای‬‫فاکتورهای‬
‫مسبب‬‫مسبب‬
QuestionQuestion
ableable‫مؤقت‬‫مؤقت‬
‫پیشرفته‬‫پیشرفته‬‫قبول‬ ‫قابل‬‫قبول‬ ‫قابل‬
‫نیست‬‫نیست‬
‫دارد‬ ‫وجود‬‫دارد‬ ‫وجود‬
‫بیشتر‬‫بیشتر‬
‫دارد‬ ‫وجود‬‫دارد‬ ‫وجود‬
‫درجه‬‫درجه‬llll‫و‬‫و‬llllll
‫دارد‬ ‫وجود‬‫دارد‬ ‫وجود‬‫قابل‬ ‫غیر‬‫قابل‬ ‫غیر‬
‫دسترسی‬‫دسترسی‬
HopelessHopeless‫پیشرفته‬‫پیشرفته‬‫مردود‬‫مردود‬‫وغیر‬ ‫دارد‬ ‫وجود‬‫وغیر‬ ‫دارد‬ ‫وجود‬‫دندان‬ ‫کشیدن‬‫دندان‬ ‫کشیدن‬‫کشیدن‬‫کشیدن‬‫دندان‬‫دندان‬‫ندارد‬ ‫وجود‬‫ندارد‬ ‫وجود‬

94. 1 - Preliminary phase:
A- Treatment of emergencies dental or {periapical
-periodontal}
B - Extraction of hopeless teeth
TEARETMENT PLANT

95. Nonsurgical Phase (Phase I Therapy)
Plaque control and patient education:
Diet control
SRP
•Correction of restorative and prosthetic irritational
factors
•Excavation of caries and restoration
•Antimicrobial therapy (local or systemic)
•Occlusal therapy
•Minor orthodontic movement
•Provisional splinting and prosthesis
Evaluation of response to no surgical phase
Rechecking:
•Pocket depth and gingival inflammation
•Plaque and calculus, caries

96. Surgical Phase (Phase II Therapy)
1- Periodontal therapy, including placement of
implants sextant or quadrant
2 -Endodontic therapy RCT
Restorative Phase (Phase III Therapy)
Final restorations
Fixed and removable prosthodontic appliances
Evaluation of response to restorative procedures
Periodontol examination
Maintenance Phase (Phase IV Therapy)
Periodic rechecking:
•Plaque and calculus
•Gingival condition (pockets, inflammation)
•Occlusion, tooth mobility

97. ‫راس‬ ‫لینگوال‬‫ت‬
‫چپ‬ ‫فاسیال‬

98. ‫از‬ ‫باال‬ ‫فك‬
9

99. * Position:
Operator--- feet are flat on the floor
and thighs parallel to floor, keeping
back straight and back erect

100. Neutral seated position Neutral neck
position

101. Neutral back position--- forward
slightly
from waist or hip

102.  Supine Patient position
Patient’s heels should be slightly higher
than tip of his nose, good blood flow to
the head
 Mouth is close to resting elbow of
operator

103. * Patient:
Instrumentation of maxi. arch, raise the chin
slightly to provide optimal visibility and
accessibility
Instrumentation of mand. arch, lower the
chin until mandible is parallel to floor

104. * Position of operator & patient

105. 105

106. * Optimum Visibility
The following methods are effective for
retraction
1) Use of mirror to deflect the cheek while the finger
of non-operating hands retract the lip and protect
the angle of mouth from irritation by the mirror
handle

107. 2) Use the mirror alone to retract lip and
cheek
3) Use the mirror to retract tongue
4) Use the fingers of non-operating hand to
retract
the lip
5) Combination of the preceding

108. *Illumination
Direct vision
and
illumination
indirect visio
and
illuminatio

109. * Illumination (dental light position)
Mand. Tx. areas Max. Tx areas

110. General principles of instrumentation
* Accessibility (position of operator &
patient)
* Visibility, illumination and retraction
* Condition of instruments
* Maintaining a clean field
* Instrument stability
* Instrument activation

111. * Condition of instruments
(sharpness)
Sharp instruments enhance tactile sensation
and allow the clinician to work more
precisely and
efficiently
* Maintaining a clean field
Saliva and gingival bleeding interfere
visibility and impede (妨礙)control

112. General principles of instrumentation
* Accessibility (position of operator &
patient)
* Visibility, illumination and retraction
* Condition of instruments
* Maintaining a clean field
* Instrument stability
* Instrument activation

113. * Instrument stability
Two factors of major importance in
providing
stability are the instrument grasp and finger
rest
a. Instrument grasp
A proper grasp is essential for precise
control
of movements made during periodontal
instrumentation

114. a. Instrument grasp
(1) Modified pen grasp
(2) Palm and thumb grasp

115. Modified pen grasp
The middle finger is positioned so that the side
the
pad next to the fingernail is resting on the
instrument shank. The index finger is bent at
second
joint from the finger tip and is positioned well
above
the middle finger on the same
side of the handle

116. Modified pen grasp

117. b. Finger rest
Serves to stabilize the hand and instrument
by
providing a firm fulcrum as movement are
made
to activate the instrument. Generally be
classified
as intraoral finger or extraoral fulcrum
* Intraoral finger rests
(1) Conventional
(2) Cross arch
(3) Opposite arch
(4) Finger on finger

118. * Intraoral finger rests
(1) Conventional
(2) Cross arch
(3) Opposite arch
(4) Finger on finger

119. b. Finger rest
May be generally be classified as intraoral
finger
or extraoral fulcrum
* Extraoral fulcrum
(1) Palm up
(2) Palm down

120. General principles of instrumentation
* Accessibility (position of operator &
patient)
* Visibility, illumination and retraction
* Condition of instruments
* Maintaining a clean field
* Instrument stability
* Instrument activation

121. * Instrument activation
1. Adaptation
2. Angulation ---Different angulation
position
will cause different effective
3. Lateral pressure
4. Strokes

122. * Adaptation: the manner in which the
working
end of a periodontal instrument is placed
against
the surface of a tooth
 To make the working end of instrument
conform to the contour of tooth surface
 To avoid trauma to soft tissues and root
surface, to ensure maximum
effectiveness
of instrumentation

123. * Adaptation
The lower third of the
working end must be
kept
in constant contact with
the tooth while it is
moving over varying
tooth contours

124. * Adaptation
If only the toe or tip is in adapted, the
soft
tissue can be distended or compressed
by
the back of the working end, also
causing trauma and discomfort, the toe
can gouge
or groove the root surface

125. *Angulation: the angle between the
face of a bladed instrument and
tooth surface, also called “tooth-
blade relationship”

126. *The working-end is inserted at an angle
between 0- and 40-degrees.
The 0-to40o angle is referred
to as a closed angle

127. *During S/RP, optimal angulation is
between 45 to 90 degrees.
The exact angulation depends on the
amount and nature of calculus, the
procedure being performed, and the
condition of the tissue

128. * Lateral pressure: the pressure created
when
force is applied against the surface of a
tooth
with the cutting edge of a blade
instrument
The exact amount of pressure applied
must be varied according to the nature
of the calculus and according to the
stroke

129. * Strokes: exploratory, scaling & root
planing
Exploratory stroke--- the instrument is
grasped
lightly and adapted with light pressure
against the
tooth to achieve maximum tactile sensation

130. Scaling stroke is a short, powerful pull
stroke
* The scaling motion should be initiated
in the forearm and transmitted from
the wrist to the hand with a slight
flexing
of the fingers

131. Wrist and forearm motion, finger flexing both
are
necessary for complete instrumentation
*The wrist and forearm motion, pivoting
in an arc on the finger rest, produce a more
powerful stroke --- preferred for scaling
*Finger flexing --- for precise control over
stroke length in areas such as line angles
and when horizontal strokes are used on the
lingual or facial aspects narrow-rooted teeth

132. Root planing stroke: a moderate to light
pull
stroke for final smoothing and planing of
root
surface
*A continuous series of long, overlapping
shaving stroke is achieved

133. Periodontal therapy
Non-surgicalSurgical
Chemotherapy
Systemic Topical
Mechanical debridement
S/RP, OHI
Subgingival curettage,
gingivectomy,
Flap, Osseous surgery,
Guided tissue regeneration

134. Scaling: instrumentation to remove
all
supragingival uncalcified
and
calcified accretions and all
gross subgingival accretion

135. Root planing: instrumentation to
remove
the microbial flora on the root surface
or
lying free in the pocket, all fleck of
calculus
and all contaminated cementum and
dentin

136. Detection skills
*Visual examination--- good light and a
clean field.
Compressed air supragingival
calculus
chalky white; subgingival calculus dark
shadow
* Tactile sensation--- light exploratory
strokes are activated vertically up and
down on root surface

137. Detection skills
* Tactile sensation--- the distance
between apical edge of calculus and
bottom of the pocket is 0.2 – 1.0 mm
* Illumination

138. The rationale for root planing
*Assumption that a smooth root surface
will be less plaque retentive and
therefore the danger of re-infection
and recurrence of disease should be
less
*Reattachment of epithelial and
connective tissue would be likely on a
smooth root surface than on a rough
one

139. Objectives of root planing
1. Securing biologically acceptable root
surface
2. Resolving inflammation
3. Reducing probing depth
4. Facilitating oral hygiene procedure
5. Improving or maintaining attachment
level
6. Preparing tissue for surgical procedure

140. * Principles for Gracey curettes
usage
1. Determine the correct cutting edge
2. Make sure the lower shank is parallel
to
root surface to be instrumented
3. Using finger rest
4. Concentrate on using lower third of
cutting edge for calculus remove
5. Moderate lateral pressure

141. * Determine cutting edge of Gracey
curette
1. Hold face of curette blade parallel
with
floor and looking down on the face
2. Notice the blade curve
3. Larger, outer curve is
the correct cutting edge

142. * The face of blade be close against
the
tooth so it can only be partially
seen

143. * Make sure lower shank is parallel
with
root surface

144. The functional shank extends from the
first bend in the shank up to working-
end
The lower shank is the bent section of
the
shank nearest to the working-end

145. To avoid over-instrumentation, a
delicate
transition from short, powerful scaling
strokes
to longer, lighter root planing strokes
must be
made as soon as calculus and initial
roughness

146. *Hoe, files and ultrasonic instruments
are
also used for subgingival scaling of
heavy
calculus but not recommended for root
planing
*Curette is preferred for subgingival
scaling and root planing

147. A common error in proximal
instrumentation
is failing to reach mid-proximal region
apical
to the contact point because this area is
relatively inaccessible and this technique
require more skill

148. * The relationship between location of
finger
rest and working area is important
1. The finger rest or fulcrum must be
position
to allow lower shank of instrument to be
parallel or nearly parallel with tooth
surface
being treated

149. * The relationship between location of
finger rest and working area is
important

150. 2. Finger rest must be positioned
enable the
operator to use wrist-arm motion to
activate strokes

151. Modes of calculus attachment reported
by
Zander in 1953
1. Attachment by means of secondary cuticle
2. Attachment of calculus matrix to
irregularities
of cementum surface corresponding
to previous insertion location of
Sharpey’s fibers

152. 3. Penetration of microorganisms of
calculus
into cementum
4. Attachment in areas of cementum
resorption
via mechanical locking into undercuts

153. Limitation of the effectiveness of scaling
and
root planing
1. Anatomy of roots
2. Depth of pockets
3. Areas of mouth being treatment
4. Inadequate instruments for diagnosis
5. Inadequate instruments for treatment
6. Range of mouth opening
7. Dexterity of operator

154. Palato-gingival groove
* Developmental abnormality
* A funnel for the accumulation of
plaque
and calculus in the depth of groove
* Prevalence on incisors ranges from 1.9
%
to 4.4 %

155. Cervical enamel projections
*Rapid progression of pocket formation
(precluding
an organic connective tissue attachment)
*Hemidesmosome attachment in CEJ  less
resistant to breakdown by bacterial plaque 
rapid
progression of disease

163. Complications of scaling & root
planing
1. Gingival bleeding
2. Bacteremias
3. Root sensitivity

164. Information to pt’ with root
sensitivity
1. Sensitivity usually temporary
2. Through plaque control
3. Not discourage if desensitizing agent
does not produce immediate effect
4. Avoid foods that heighten sensitivity

165. Root desensitization agents
Silver nitrate, 10% strontium chloride,
NaF,
formaldehyde, stannous fluoride, 5%
KNO3
Ionotophoresis

173. ‫کنید؟‬ ‫بیان‬ ‫را‬stain ‫ایجادی‬ ‫عوامل‬ ‫از‬ ‫دوعلت‬

174. Periodontal Maintenance Therapy
Dentistry 565 – Evidenced-based periodontics

179. What is PMT?
 PMT = Periodontal MaintenanceTherapy
 also know as:
supportive periodontal therapy (SPT)
preventive maintenance
recall maintenance
 procedures performed at selected intervals
to assist the periodontal patient in
maintaining oral health

180. Rationale for PMT
 tooth loss inversely proportional to SPT
frequency
 reduced risk of future attachment loss
despite incomplete plaque removal
 monitoring
 plaque removal

181. Therapeutic goals for PMT
 To prevent or minimize the recurrence and
progression of periodontal disease in patients
who have been previously treated for
periodontal diseases.
 To prevent or reduce the incidence of tooth loss
by monitoring the dentition and any prosthetic
replacements of the natural teeth.
 To increase the probability of locating and
treating, in a timely manner, other diseases or
conditions within the oral cavity.

182. Components of PMT appointment
 update medical/dental histories
 extraoral/intraoral soft tissue examination
 dental examination
 periodontal evaluation

183. Components of PMT appointment
 radiographic review
 assessment of disease status

184. Components of PMT appointment
 assessment of personal oral hygiene
removal of dental plaque and calculus from
supragingival and subgingival regions
behavioral modification
root planing
occlusal adjustment
Antimicrobial agents
Surgical treatment

185. Components of PMT appointment
 communication
 planning

186. Frequency of PMT
 For most patients presenting with
gingivitis but without history of
attachment loss- performed on a
semiannual basis.
 For patients with a history of
periodontitis, PMT should be performed
at intervals of less than 6 months -
most commonly every 3 months.

187. Duration of PMT appointment
 teeth
 cooperation
 oral hygiene
 systemic health
 frequency
 instrumentation
 history
 sulci

188. The effect of plaque and frequency
of recall on PMT.
Change in Probing Attachment Level
(sites > 6 mm)
0
1
2
3
1 2 3 4 5 6 7 8
Years
AttachmentLevel
(mm)
Low plaque
High plaque

189. Compliance
 16% comply with PMT
 49% comply erratically with PMT
 34% never reported for PMT

190. Who is best at providing PMT?
 general dentist
 periodontist

191. Summary
 Successful periodontal therapy with PMT
 PMT follows active periodontal therapy
 PMT under the supervision of a dentist
 An interval of 3 months between
appointments

192. Sample Test Question
Which of the following is the MOST
appropriate PMT interval for patients
following active periodontal therapy?
A) 3 months
B) 4 months
C) 5 months
D) 6 months

193. Answer: A
 Patients who have received active
periodontal therapy should obtain PMT 4
times per year, since this interval will result
in a decreased likelihood of progressive
disease, compared to patients receiving
PMT on a less frequent basis.

194. ‫از‬ ‫پس‬ ‫زیر‬ ‫ضایعه‬48‫بصورت‬ ‫ساعت‬
‫است؟‬ ‫زیرکدام‬ ‫ضایه‬ ،‫است‬ ‫برآمده‬ ‫ای‬ ‫قله‬

195. Position and scaling &Root planing

196. ‫پائین‬ ‫فك‬
‫فاسیال‬ ‫راست‬
‫لینگوال‬ ‫چپ‬
8‫تا‬9
‫لینگوال‬ ‫راست‬
‫فاسیال‬ ‫چپ‬
9‫تا‬11
‫قدامي‬ ‫ناحیه‬
‫باال‬ ‫فك‬ ‫چه‬
‫پائی‬ ‫فك‬ ‫چه‬‫ن‬
‫چ‬ ‫فاسیال‬ ‫چه‬‫ه‬
‫لینگوال‬
‫ساعت‬ ‫در‬
8‫تا‬9
‫یا‬
11‫تا‬12
‫باال‬ ‫فك‬
‫فاسیال‬ ‫راست‬
‫پاالتال‬ ‫چپ‬
9
‫پاالتال‬ ‫راست‬
‫فاسیال‬ ‫چپ‬
9‫تا‬10(11)

197. ‫راست‬ ‫فاشیال‬
‫چپ‬ ‫لینگوال‬