Faculty of Dentistry Fourth year Periodontics · In any periodontitis case , the bone loss is an irreversible process , so when you treat it , you relieve the symptoms , after the

Hadeel Al-Jarhi

Murad

2

9/2/2015

Periodontics

Lecture No.

Date:

Doctor:

Done by:

Sheet

Slide

s

Hand Out

University of Jordan

Faculty of Dentistry

Fourth year –2nd semester 2014-2015

9/2/2015 perio sheet#2 Hadeel Al Jarhi

2

Examination and diagnosis of periodontal diseases :

Lecture outline:

- Patient interview

- Periodontal examination and charting

- Periodontal probing

- Mobility

- Recession

- diagnosis

When you examine a patient , especially for the first time ,always look at the big picture of the case, do not

focus on small details .

These gingival diseases were or will be covered in the lectures :

There's another table in the slides show each disease features .

Patient interview

Chief complain

- History of chief complaint :

in perio clinic it could be ( pain , mobility , bleeding , bad breath , recession , diastema formation ,

spacing between teeth , esthetics ;black triangles which form because of the papillary recession)


3

you then investigate the chief complain ( onset , location , duration , aggravating and relieving

factors & nature of the complaint )

*ask smart questions

*do not use scientific terms with the patient , use simple words instead .

Eg:

2 patients have bleeding of the gum as a chief complaint :

Case 1 : stated 2 weeks ago , not associated with swelling and the bleeding stops shortly after teeth

brushing .

Case 2 : started 2 weeks ago , associated with generalized swelling , and the bleeding lasts for

several hours

Which case is more ominous ? case 2

Case 1 is more like plaque induced gingivitis

Case 2 as the bleeding last for several hours , that’s indicate that it's something different than the

plaque induced gingivitis

In the gingival index , 3 = spontaneous bleeding which is not an accurate description , as almost

there's no real spontaneous bleeding ( it has to be stimulated even by a fine touch of the gingiva )

Eg . If a patient has mobility as a chief complain , you could ask him :

1- When did you first feel it

2- Did it start after a specific incident

3- has the nature of the complaint changed recently

chief complain could appear after a restorative treatment , so occlusal changes happen and lead to

changes in teeth

Medical history :

-Investigate systematically

-ask the patient if he/she is regularly attending a physician

- it's important to determine if the patient is prone to infective endocarditis ( patients with prosthetic heart

valve and congenital heart diseases are usually aware that they should stop the warfarin before visiting a

dentist )

- you can't probe for these patients without using an antibiotic prophylactically as probing induces

bacterial invasion and infection.

- it's important to ask about smoking ( what type of tobacco , amount per day and for how long he/she has

been smoking )


4

Smoking is a risk factor for periodontitis

-using the medical screening form is recommended ( as you could let the pt fill

it and investigate the positive answers only )

- you can consult a physician if you need to ( ask specific questions )

Eg : never ask the physician how to manage my patient , ask questions like

please update me with the cardiovascular status of the pt , or please advise if

we can use epinephrine in the LA

You should be cautious in using epinephrine with patients having diseases like

hypertension , ( the quantity per time )

If you gave him 2 carpools of LA , after 2 hours you should be aware of giving

him LA again as we have endogenous adrenaline secretion .

- Social an family history

Social Hx : smoking , alcohol use , recreational drugs use

Family Hx : for medical conditions and periodontal diseases

Eg. Do you have any relatives who have lost their teeth in an early age ?or have mobility in teeth ? or have

any gum disease

- Dental history

Previous perio treatment :

- It could impact the way you diagnose the condition

Eg. A pt who has been treated of chronic periodontitis (recession and exposure of the roots and you had

done scaling and root planning for him ) , when he has been examined for the next time he may have

bleeding upon probing and that doesn’t mean that he has active periodontitis , he may have gingivitis on a

reduced periodontium.

In any periodontitis case , the bone loss is an irreversible process , so when you treat it , you relieve the

symptoms , after the treatment , having bleeding on probing doesn’t mean that he/she still have active

periodontitis or bone loss , its gingivitis on the reduced periodontium

So you have to ask about the previous treatment to have good diagnosis , ant it could be helpful if you can

get the previous perio charting


5

Eg. A pt who has been treated from periodontitis previously but still have active signs of the disease (

suppuration , severe pocketing , sub gingival calculus ) that indicate it's such a tough case that didn’t

respond to treatment as it was predicted ,

- Oral hygiene attitude ( what he/she use ,how many times and so )

- Orthdontic tx history ( could cause root resorption r blunting , recession )

Examination :

- extra oral examination ; muscles of mastication , TMJ , skin , lips , symmetry , lymph nodes

- intra oral examination ; caries , prominent wear facets , uneven marginal ridges , failing restorations ,

evidence of food impaction , tenderness to percussion , fremitus

Fremitus : tooth mobility upon function ; when the pt bite , the first tooth to come in contact with the

opposing , move a little to allow for maximum intercuspation .

Its seen most commonly in the maxillary anterior teeth but could be anywhere , it could happen upon

either centric or eccentric movement .

Fremitus in eccentric movement happen in the posterior teeth ;

In normal occlusion , when we have eccentric movement , there's no non- working side contact , but in

some cases

A non-working side contact happens , which lead to excessive load and mobility of teeth upon function

(fremitus).

Periodontal examination :

Visual inspection

Periodontal probing

Assessment of mobility

Assessment of plaque and calculus

Visual inspection


6

Check color

size(presence of swelling)

changes in the position of gingival margins ( like gingival recession )

loss of stippling ; it's not a sensitive indicator unless you know that the patient had stippling

before as many people don't have stippling in their gingiva.

this pt had gingival swelling , sub gingival calculus ,

the chief complaint : bleeding

she had scaling and polishing but she wasn't improving

after a good perio treatment ( removing of sub gingival calculus ) she improved

the formation of black triangles was a result of the bone loss she

had, it was there before the treatment but was masked by the swelling , but

you can do either restorative Tx or veneers to hide the black triangles

and by visual inspection you can see if there's any necrotic areas

or gingival recessing

(localized )

Generalized gingival recession


7

Check the miller classification for gingival recession form the

slides

Visual inspection includes root caries , or severe recession as seen here

- Periodontal probing

Probing depth vs. pocket depth

Probing depth : The degree of penetrating of the periodontal probe (clinical measure )

Pocket depth : histological term refers to the depth from the gingival margin to the most coronal cell of the

gingival sulcus

The difference is there because the tip of the probe does not stop at the most

coronal cell of the junctional epithelium ( it just enters it )

The degree the penetration depend on :

1. The level of inflammation ( if the tissues are inflamed the probe tip

penetrates all the way through junctional epithelium and lands in the

connective tissue , after treating the pt , the tissues resist the penetration

of the probe tip and it stops more coronally)

2. The size of the probe

3. The angle of penetration

4. The presence of sub gingival calculus

5. The presence of certain anatomical varieties like enamel pearl or grooves

There're interoperator , intraoperater and intraobservor variability of measurement

We use either

Perio probes


8

Naber probes : for furcation areas

Probing in the interproximal areas :

You have to probe under the contact into the Midproximal , (not at the line

angles of the tooth)

Probing at the line angle , subgingival calculus , bulky restoration could cause an

error in determining the probe depth .

Furcation assessment

- Aim to determine the amount of bone loss

Horizontally ( in the furcation )

- So we measure the horizontal penetration by naber 's

Probe which is divided to increments f 3 mm

When the periodontal disease progress to the root trunk , the plaque extends to the root surface , so the

infection spreads to the furcation making bone loss ( furcation invasion ) , and that worsens the prognosis of

the tooth and makes it more difficult to treat .

We use Hamp classification of furcation involvement :

Grade I - The furcation can be probed to a depth of 3 mm horizontally . Using the probe, the

anatomic fluting between the roots can be felt, but cannot engage the roof of the furcation.

Grade II - The furcation can be probed to a depth greater than 3 mm, but not through and through.

Grade III The furcation can be completely probed through and through subgingivally regardless of

the soft tissues .

Grade IV The probe goes completely through the furcation and is supragingival.


9

We assess the mobility using 2 instruments or our finger + an instrument Grade I : up to 1 mm Grade II : more than 1 mm in the buccolingual or mesiodistal direction Grade III : movement is greater than 1 mm in any direction and is depressible in the socket

Pus (suppuration) can be found upon probing

Calculus assessment :

- Visual inspection :

Used to detect the Supragingival calculus , or the subgingival calculus if the gingival margin was detached

- Tactile sensation

Using perio probe , periodontal explorer , curettes

The perio chart :

It shows the upper and lower teeth .

The facial and lingual surface of each tooth

Each part is divided into 3 sites as we probe 6 sites ( 3

facially and 3 lingually )

We have to probe to determine the gingival index and the

plaque index


10

We probe 6 sites for each tooth and determine the PSR .

( in the clinics we have to probe only the sextants which have the PSR value as 3 or 4 )

Charting guidelines :

1- Start by Eliminating the missing teeth from the chart

2- write roman latters on the crown to represent mobility of each tooth

3- if there's a furcation invasion use a ( < ) symbol to

refer to the root that has furcation invasion Grade I

4- if the furcation is grade II , used a triangle pointing to the root

that has it .

5- use a cycle to refer to impacted/ unerupted teeth

6- Use an arrow to indicate drifting


11

7- Outline the surfaces involved in any carious lesions , and color in the areas in red to be

restored and blue for already restored.

8- Charting includes 6 sites for each tooth

( GM = gingival margin ,normally it should be coronal to the CEJ , if it was 0 = at the CEJ

BOP=bleeding on probing ( use a dot if there's bleeding and leave it if no bleeding present )

PD= probing depth )

9- Chart recession and bleeding

Periodontal pocketing is usually 5 mm or above ( assuming that it's not a pseudo pocket )

In pseudo pocket : the gingival margin migrates coronally

In a healthy situation , connective tissue is attached to the CEJ of the

root , more coronally , the Junctional epithelium lies the base of the

gingival sulcus.

In a case of periodontitis / periodontal bone loss , this complex Migrates more apically , so the part of the root which was covered by connective tissue will be exposed ( loss of attachment ) , but still there will be a part of the root covered by junctional epithelium

This is clinical attachment loss

Eg. If the probing depth was 8mm , and the clinical recession was 1mm , the clinical attachment loss will be

9mm

General rules :

When recession of the gingival margin is present, the CAL is calculated by adding the probing depth to the

gingival margin level

Example:


12

Probing depth measurement: 4 mm Gingival margin level: +2 mm* Clinical attachment loss: 6 mm

When the gingival margin is coronal to the CEJ, the CAL is calculated by subtracting the gingival margin level from the probing depth. Example: Probing depth measurement: 9 mm Gingival margin level: -3 mm* Clinical attachment loss: 6 mm

When the gingival margin is slightly coronal to the CEJ, no calculations are needed since the probing depth and the clinical attachment level are equal. Example: Probing depth measurement: 6 mm Gingival margin level: 0 mm* Clinical attachment loss: 6 mm

Remember : the root (cementum) of any healthy tooth should all be covered by PDL fibers

The bone is 1-2 mm away from the CEJ and attached to it by dentogingival fibers (PDL fibers )

The exposed part of the root represents the clinical attachment loss ( exposed doesn’t mean recession away , it's

any loss of attachment detected by probing )

Radiographic examination

- Used to detect horizontal or vertical bone loss )


13

- An imaginary line is drawn between the CEJ of adjacent teeth , if the contour of the alveolar bone

is parallel its either normal situation or horizontal bone loss , if its perpendicular to the contour it’s

a vertical bone loss .

- the presence of radiolucency in the furcation area doesn’t mean

that

there's furcation invasion unless its proved clinically

as this radiolucency could be caused by a perforation after endo

Tx

- A full mouth series is usually needed ( panorama x-ray can be used too)

- Vertical bitewings are used to detect the bone loss

- The major difference between gingivitis and periodontitis is the plaque induced attachment loss

- Gingivitis is not progressive , periodontitis is a progressive

disease causing bone loss

- In this case the patient has periodontitis , if the patient was left

without treatment , the disease will progress , he/she will have

more bone resorption and attachment loss , even if he/she

doesn't have pockets

- Pockets presence is a very important periodontal parameter but its not the primary difference

between gingivitis and periodontitis

*I added extra informations to clarify some points*

Good Luck .

Documents

Faculty of Dentistry Fourth year Periodontics · In any periodontitis case , the bone loss is an irreversible process , so when you treat it , you relieve the symptoms , after the