advanced diagnostic aids in periodontics

advanced diagnostic aids

1. Advanced diagnostic aids

2. contents Introduction Efficacy of diagnostic test Limitations of conventional methods Advances in Clinical diagnosis A dvances in Radiographic assessment Advances in microbiologic analysis Advances in charaterizing the host response New innovations Conclusion References

3. introduction Proper diagnosis  Intelligent treatment Diagnosis Involves Analysis of case history Evaluation of clinical signs and symptoms Results of tests (Probing, Mobility, Radiograph, blood test, biopsies) Diagnosis Determines Presence of disease Type of disease Underlying disease process

4. A “Diagnostic” refers to tools, procedures or technologies that are used in determination of diagnosis used to: a) predisposing risk factors b) identify early disease c) specific type of disease Kornman,2005

5. EFFICACY OF DIAGNOSTIC TEST Gold standard Accuracy Sensitivity Specificity Positive predictive value Negative predictive value

6. Conventional clinical diagnostic tools

7. limitations Sites with ongoing periodontal destruction Cause Patient’s susceptibility to disease whether disease is progressing?? remission?? response to periodontal therapy  + /- ??

8. Advances in clinical diagnosis

9. Advances in clinical diagnosis Periodontal probes Non-Periodontal probes - Calculus detection system - Periodontal Disease Evaluation System - Gingival Temperature - Tooth mobility

10. Gingival bleeding Assessment of Redness Swelling Gingival bleeding Inflamed periodontal tissues bleed when probed with a blunt instrument because there are frequently microulcerations in the epithelium that lines the soft tissue wall of a periodontal pocket

11. Gingival bleeding Sensitive clinical indicator of early inflammation More objective than change in colour Severity is proportional to the size of inflammatory infiltrate Lang et. al. 1986  force > 0.25 newton evokes bleeding in sites with intact periodontium Limited predictive value Absence  Periodontal stability

12. Periodontal probes Orban as the “ eye of the operator beneath the gingival margin ” Latin word “ Probo ”, which means “ to test ”. Gold standard Simonton (1925) and Box (1928) were among the first to advocate the routine use of calibrated probes locate calculus, measure gingival recession, width of attached gingiva and size of intraoral lesions, identify tooth and soft-tissue anomalies, locate and measure furcation involvements and determine mucogingival relationships and bleeding tendencies.

13. Types of probe: Pihlstrom (1992) classified probes into three generations. In 2000, Watts extended this classification by adding fourth- and fifth-generation probes.

14. First-Generation (Conventional) Probes: conventional hand-held instruments. Probes do not control for probing pressure and are not suited for automatic data collection. Willams ’ Periodontal probe: 1936, Charles H.M. Williams Prototype/benchmark

15. 2. Community Periodontal Index of Treatment Need (CPITN): Professor George S. Beagrie & Jukka Ainamo 1978 FDI World Dental Federation/WHO Joint Working Group CPITN-E (epidemiologic)  3.5mm & 5.5mm CPITN-C (clinical) 3.5mm,5.5mm,8.5mm & 11.5mm 5gm wt, ball tip 0.5 mm

16. 3 . University of Michigan O probe : 3mm, 6mm & 8mm 4 . University of North Carolina-15 (UNC-15): 5. Naber’s probe: Furcal areas

17. Second-Generation (Constant-Pressure) Probes: Pressure sensitive , not exceed 0.2 N/mm 2 ( Waerhaug , 1952) True Pressure Sensitive (TPS) probe: Prototype , Hunter 1994 Disposable probing head 20 gm & 0.5mm dia

18. First true pressure-sensitive periodontal probe : Gabathuler and Hassell (1971) periodontal probe & a small piezoelectric pressure sensor which was attached to the non-probing end of the probe tip.

19. In 1977, Armitage : Simple pressure-sensitive periodontal probe holder : To standardize the insertion pressure. In 1978, van der Velden presented the " Pressure Probe ", which allowed probing force to be adjusted. Cylinder & a Piston connected to a variable air pressure system

20. The electronic pressure-sensitive probe , allowing for control of insertion pressure, was introduced by Polson in 1980 . Polson’s original design was modified: the probe is known as the Yeaple probe , which is used in studies of dentinal hypersensitivity (Kleinberg et al., 1994). A simple, constant-force, periodontal probe was presented by Borsboom and co-workers (1981). Their instrument used a stainless steel spring to generate constant force.

21. Kalkwarf et al 1986: force upto 30 g  Junctional epithelium 50 g periodontal osseous defects

22. Third-Generation (Automated) Probes: Controlled force application, automated measurement and computerized data capture and storage Foster-Miller probe (Foster-Miller Inc, Waltham, MA): prototype. Jeffcoat et al. in 1986, capable of automated cemento -enamel junction (CEJ) detection and direct measurement of attachment level with a high level of repeatability and accuracy.

23. National Institute for Dental and Craniofacial Research (NIDCR):

24. Gibbs et al. (1988) developed the Florida Probe ® system (Florida Probe Corp, Gainesville, FL): constant probing force, precise electronic measurement to 0.1 mm and computer storage of the data and sterilization of all system parts entering or close to the mouth

25. CAL- Fixed reference point occlusal surface of teeth- disk probe prefabricated stent- Stent probe Florida PASHA Probe - Modified sleeve, tip edge 0.125 mm “catch” of the CEJ

26. Birek et al. ( 1981) and McCulloch et al. ( 1981) developed the Toronto Automated probe : It used the occlusal / incisal surface to measure relative clinical attachment levels. Goodson and Kondon (1988) used fiber optic technology in their controlled-force Accutek probe . The InterProbe ™ (The Dental Probe Inc, Glen Allen, VA), also known as the Perio Probe , is a third-generation probe with a flexible probe tip , Jeffcoat 1991

27. Fourth generation probes: T hree-dimensional (3D) probes . Currently under development

28. Fifth-Generation Probes: 3D and non-invasive: an ultrasound or other device is added to a fourth-generation probe. aim to identify the attachment level without penetrating it. The only fifth-generation probe available, the Ultrasonographic (US) probe (Visual Programs, Inc, Glen Allen, VA), uses ultrasound waves to detect, image and map the upper boundary of the periodontal ligament and its variation over time as an indicator of the presence of periodontal disease. Hinders & Companion at the NASA Langley Research Center .

29. NON-PERIODONTAL PROBES Calculus Detection Based on measurements of resonance vibrations of ultrasonic treatment or autofluorescence induced by laser irritation. Recently, a novel calculus detection system DetecTar ( Ultradent , Salt Lake City, UT, USA) employing spectro -optical technology has been suggested as a potential aid in detecting subgingival calculus

30. Periodontal Disease Evaluation System The Diamond Probe/ Perio 2000 System ® is a dental device designed to detect sulphide concentrations of various forms (S, HS, H 2 S and CH 3 SH) in gingival sulci The system combines a conventional Michigan “O” style dental probe with a sulphide sensor, which measures periodontal probing depth, bleeding on probing and sulphide levels simultaneously

31. Gingival temperature Increased blood flow and a very high metabolic rate Kung et al  Sensitive diagnostic devices for measuring early inflammatory changes in the gingival tissues PerioTemp probe ( Abiodent ) = sensitivity of 0.1 o C 2 light indicating diodes : Red-emitting diode higher temp Green-emitting diode lower temp

32. Diseased sites Posterior teeth Mandibular sites Temp increases with probing depth = Unknown Haffajee et. al., 1992  sites with higher temperature have greater than twice the risk of future attachment loss Pathogens Increased temperature Unclear

33. Tooth mobility Periotest Probe is a hand-held probe, Mobility is recorded in Periotest units (PTU) from 0 to 50. The instrument ( BioResearch , Milwaukee, Wisconsin, USA) taps each tooth with an impeller 16 times and measures the time taken for the tooth to return to its original position.

34. Advances in radiographic assessment

35. Destruction of alveolar bone Cannot accurately reflect bone morphology= buccally / lingually Interproximal bone levels Root length, root proximity, presence of periapical lesions, estimates of remaining alveolar bone. More than 30% of bone mass  lost Conventional radiographs are very specific but lack sensitivity

36. Commonly used Bitewing Periapical Panoramic Variations in projection geometry Variations in contrast & density caused by differences in film processing, voltage, & exposure time & Masking of osseous changes by other anatomic structures (2D mapping of 3D structures)

37. Advances in radiographic assessment Digital radiography Digital subtraction radiography Computer-assisted densitometric image analysis system (CADIA) Tuned aperture computed tomography (TACT) Computed tomography (CT) Cone-beam computed tomography (CBCT) Local computed tomography (LCT) Magnetic resonance imaging (MRI) Nuclear medicine bone scans Optical coherence tomography (OCT) Ultrasound imaging

38. Digital radiography Advantages: The elimination of chemical processing. Shorter exposure-to-display time. 1/3 rd to 1/2 rd of dose reduction Computerized images which can be stored Selected region in the image can be enhanced for a specific diagnostic task. The software offers a variety of measurement tools

39. Two digital radiography systems rely on the sensor – Direct method  solid-state detectors which are based either on charge-coupled device technology (CCD) or on complementary metal oxide semiconductor technology (CMOS) key features is the immediate availability of the image Disadv : limited x-ray sensitive surface of the sensor thicker, rigid & cable attachment besides sterility issue.

40. I ndirect methods : ( Digora System) uses a phosphor luminescence plate, which is a flexible film-like radiation energy sensor placed intraorally and exposed to conventional X-ray tubes. Adv : plate size and flexibility plates are then erased and can be reused. Disadv : increased time and effort for scanning

41. Digital Subtraction radiography First demonstrated by Zeidses Des Plantes,1935 Principle: current image is superimposed on the previous. Only the areas of change appear positive difference  brighter negative difference  darker Baseline project geometry and image density must be reproduced

42. A high degree of correlation between changes in alveolar bone determined by SR & CAL changes in periodontal patients after therapy Increased detectability of small osseous lesions. Disadv : identical projection alignment during sequential radiograph Diagnostic subtraction radiography (DSR)  positioning device + specialized software

43. Computer-assisted densitometric image analysis system Video camera measures the light transmitted through a radiograph and the signals from the camera are converted into gray-scale images. higher sensitivity and a high degree of reproducibility and accuracy.

44. Tuned aperture computed tomography (TACT) To assess tissues in three dimensions Based on the principle of tomosynthesis : By shifting and combining a set of basis projections, arbitrary slices through the object can be brought into focus Improves detection of defects around implants Tyndall et al., 2002  TACT is superior to conventional radiography in detecting pericrestal bone gain

45. Computed tomography (CT) In 1972, Godfrey Hounsfield The X-ray source travels helically around the patient many times, emitting a narrow fan beam until the region of interest is covered. The beam exiting the patient is captured in a digital sensor Axial, coronal or sagittal planes This is referred to as multiplanar reformatted imaging

46. Indication  for evaluating prospective implant sites for the amount & character of remaining alveolar bone. Fuhrmann et. al., 1995  CT assessment of alveolar bone height and intrabony pocket is reasonably accurate Dentascan :

47. Cone-beam computed tomography (CBCT) reduced dose of radiation

48. Drawbacks: increased effect of scatter radiation on image quality. Scatter radiation reduces contrast and limits the imaging of soft tissues. CBCT is mainly indicated for imaging hard tissues .

49. Local computed tomography (LCT) A form of CBCT Uses a small field high resolution detector to generate a limited high resolution 3D volume advantages of reduced patient dose and low cost Limited commercial availability

50. Magnetic resonance imaging (MRI) Non-ionizing radiation from the radiofrequency (RF) band Soft tissues have a high water content, MRI provides excellent soft tissue contrast resolution

51. Adv: It offers the best resolution of tissues of low inherent contrast. No ionizing radiation is involved Since the region of the body imaged is controlled electronically, direct multiplanar imaging is possible without reorienting the patient.

52. Disadv : expensive, requires considerable scan time for high resolution images may be claustrophobic for the patient the potential of causing movement of ferromagnetic metals in the vicinity of the imaging magnet Metals used in dentistry for restorations or orthodontics will not move but may distort the image in their vicinity

53. Nuclear medicine bone scans Radiolabeled pharmaceuticals that are specifically intended to image particular organs or detect specific disease processes. assessing physiologic change in the absence of anatomic change. technetium- labeled diphosphonate called 99m-Tc-methylene diphosphonate

54. To perform a bone scan, the radiopharmaceutical is injected intravenously. Following a period to allow for bony uptake of the agent, uptake is either imaged using a gamma camera or measured using specially designed detectors for intraoral use. Areas of active bone loss appear as hot spots in the image

55. Used : determine whether a patient has active sites of bone loss and could benefit from an experimental treatment, to determine whether a patient who is to undergo a bone marrow transplant has sites of active periodontal disease or occult disease that need immediate attention.

56. Optical coherence tomography (OCT) Biologic imaging system in 1991 by Huang et al high-resolution cross-sectional images of biologic structures by scanning a lightly focused light beam across the tissue It uses broadband low-coherent Near-Infrared (NIR) light sources Dental OCT images clearly depict anatomical structures that are important in the diagnostic evaluation of both hard and soft oral tissue

57. Periodontal tissue contour, sulcular depth and connective tissue attachment Active periodontal disease before significant alveolar bone loss occurs. 3D imaging of periodontal soft tissues and bone

58. Ultrasound imaging Ultrasonics is a branch of acoustics concerned with sound vibrations in frequency ranges above audible level. Ultrasound imaging, or ultrasound scanning or sonography , is a method of obtaining images from inside the human body through the use of high frequency sound waves. Non-invasive periodontal assessment tool 1 to 20 megahertz Spranger (1971) who tried to determine the height of the alveolar crest

59. Adv: ultrasound imaging can visualize periodontal and oral tissues in vivo or ex vivo without the need for complicated processing, fixing or staining. It is fast, easy and a reproducible technique. non-invasive nature of the imaging the avoidance of ionising radiation,

60. Advances in microbiologic analysis

61. Diagnostic microbiology- involves the study of specimens taken from patients suspected of having infection More than 300 species isolated from different individuals 40 species from a single site

62. According to criteria described by Socransky - 1) Strong evidence for Aa , Pg, Tf 2) Moderate evidence for campylobacter rectus, eubacterium nodatum , fusobacterium nucleatum , peptostreptococcus micros, prevotella intermedia , prevotella nigrescens , streptococcus intermedius , and spirochetes such as treponema denticola

63. Microbiological tests are useful.. 1) To identify putative pathogens and supporting the diagnosis of various forms of periodontal disease 2) To serve as indicators of disease initiation and progression and healing 3) To determine which periodontal sites are at higher risk for active destruction

64. 4) To monitor periodontal therapy 5) To aid in treatment planning of patients with aggressive or non responding periodontitis by helping the doctor in selection of adjunctive antimicrobial therapy

65. Advances in microbiologic analysis Bacterial culturing Direct Microscopy-dark-field or phase-contrast microscopy Immunodiagnostic methods Enzymatic methods Diagnostic analysis based on Molecular Biology techniques

66. Advances in characterizing the host response Diagnostic tests have been developed that add measures of the inflammatory process to conventional clinical measures. Information on the destructive process Current activity of the disease Rate of disease progression Patterns of destruction Extent & severity of future breakdown Response to therapy

67. Assessment of the host response refers to the study of mediators, by immunologic or biochemical methods, that are recognized as part of the individual’s response to the periodontal infection Inflammatory mediators & products Host-Derived Enzymes Tissue Breakdown products

68. New innovations Proteome analysis Genetic analysis

69. Proteome analysis: Salivary proteome : using both two-dimensional gel electrophoresis ⁄ mass spectrometry and ‘shotgun’ proteomics approaches Hu et al. (2005) identified 309 distinct proteins in human whole saliva NIDCR support salivary proteome projects, 1,166 salivary proteins 3 key features of pathogenic processes in periodontal disease - inflammation, collagen degradation and bone turnover.

70. GCF Proteomes: The composition of GCF greatly varies between health and periodontal disease. Bostanci et al. (2010) performed analysis of the from healthy and periodontally diseased sites 154 proteins of human, bacterial and viral origin were identified in the 40 GCF samples obtained from the 10 subjects The proportion of bacterial, viral and yeast protein was increased in disease compared to health

71. Genetic analysis: The etiology of periodontal disease is multifactorial and thus influenced by genetics (i.e. the host) and the environment The periodontitis susceptibility trait test (Interleukin Genetics, Waltham, Massachusetts) is the only genetic susceptibility test for severe periodontitis that is commercially available. This system works by detection of two types of IL-1 genetic alleles, IL1A +4845 and IL1B +3954

72. conclusion After all these years of intensive research, we still lack a proven diagnostic test that has demonstrated high predictive value for disease progression, has an impact on disease incidence & prevalence, & is simple, safe & cost-effective…. Future application of advanced diagnostic techniques will be of value in documenting disease activity & treatment options.

73. references Newman MG, Takei HH, Klokkevold PR, Carranza FA . 10 th edition. Carranza’s Clinical Periodontology . Saunders Company 2006. 579-601. Ramachandra SS, Mehta DS, Sandesh N, Baliga V, Amarnath J. Periodontal Probing Systems: A Review of Available Equipment. Dentistry India 2009; 3(3): 2-10. Jeffcoat MK, Wang IC, Reddy MS . Radiographic diagnosis in periodontics . Periodontol 2000 1995; 7: 54-68.

74. Bostanci N, Heywood W, Mills K, Parkar M, Nibali L, Donos N. Application of label-free absolute quantitative proteomics in human gingival crevicular fluid by LC/MS E (gingival exudatome ). J Proteome Res 2010; 9(5): 2191-2199.