Carranza's Clinical diagnosis

Chapter 30 Clinical Diagnosis - Carranza's Clinical Periodontology 11th Edition

1. CLINICAL DIAGNOSIS

2. FIRST VISIT Overall Appraisal of the Patient Medical History Dental History Intraoral Radiographic Survey Casts Clinical Photographs Review of the Initial Examination

3. SECOND VISIT Oral Examination Examination of the Teeth and Implants Examination of the Periodontium A Periodontal Diagnosis should determine : Presence of disease 2. Identify the type Extent 4. Distribution 5. Severity 6. Understanding of cause

4. Gingival Diseases Chronic marginal gingivitis Acute necrotizing ulcerative gingivitis Acute herpetic gingivostomatitis Allergic gingivitis Gingivitis associated with skin diseases Gingivitis associated with endocrine-metabolic disturbances Gingivitis associated with hematologic-immunologic disturbances Gingival enlargement associated with medications Gingival tumors

5. Features of Types of Periodontitis

6. FIRST VISIT Overall Appraisal of the Patient Mental and emotional status Temperament Attitude Physiologic age

7. Medical History

8. The possible role of some systemic disease, conditions and behavioral factors. Presence of condition may require caution. The possibility that oral infections may have a powerful influence on the occurrence and severity of a variety of systemic diseases and conditions.

9. Dental History Current illness May be unaware of any problem Bleeding gums Loose teeth Foul taste Itchy gums Pain (Variable) Sensitivity (Hot, Cold, Chewing, Air inhale, Burning)

10. Intraoral Radiographic Survey consist of a minimum of 14 intraoral films and four posterior bite-wing films

11. Panoramic radiographs are a simple and convenient method of obtaining a survey view of the dental arch and surrounding structures. They are helpful for the detection of developmental anomalies, pathologic lesions of the teeth and jaws, and fractures as well as dental screening examinations of large groups. but a complete intraoral series is required for periodontal diagnosis and treatment planning

12. CASTS Position of gingival margins Position and inclination of the teeth Proximal contact relationship Food impaction areas View of lingual- cuspal relationship Visual aid in discussion and comparison Position of implant placement (If required)

13. Clinical Photographs To record appearance of the tissue before and after treatment, Gingival morphologic changes

14. Review of the Initial Examination

15. Second Visit Oral Examination Oral Hygiene Food Debris Plaque (Not necessary to relate) Tooth surface stains

16. Oral Malodor (Halitosis) May be either oral or extra-oral Examination of the Oral Cavity Lips Floor of the mouth Palate Tongue Oropharyngeal region Quality and Quantity of saliva

17. Examination of Lymph Nodes Lymph nodes can become enlarged and hard as a result of infectious episode, malignant metastases and residual fibrotic changes. Inflammatory nodes become: Enlarged, Palpable, tender and fairly immobile Red and warm overlying skin Primary herpetic gingivostomatitis , necrotizing ulcerative gingivitis (NUG), and acute periodontal abscesses may produce lymph node enlargement

18. Examination of the Teeth and Implants Caries Poor restorations Developmental defects Anomalies of the tooth form Wasting (Erosion, Attrition, Abrasion) Hypersensitivity Proximal contact relationship The stability, position, and number of implants and their relationship to the adjacent natural dentition is also examined.

19. Dental Stains Examined carefully to determine the origin Hypersensitivity Root surface exposed by gingival recession Proximal Contact Relations Open contact allow food impaction

20. Tooth Mobility Night<Morning (with slight extrusion) Single rooted>Multi-rooted (incisors having the most) Stages of tooth mobility: Initial = 100lb order of 0.05mm to 0.10mm Secondary = 500g 1-2mm(incisors) 0.5-0.9mm(canines) 0.08-0.1mm(premolars) 0.4-0.8mm(molars)

21. • Normal mobility • Grade I: Slightly more than normal. • Grade II: Moderately more than normal. • Grade III: Severe mobility faciolingually and/or mesiodistally , combined with vertical displacement

22. Increased mobility is caused by one or more of the following factors Loss of tooth support(Bone loss) Trauma from occlusion Extension of inflammation Periodontal surgery Pregnancy Pathologic processes of the jaw ( osteomyelitis and tumors of the jaw(

23. Trauma from occlusion Excessive tooth mobility Widened periodontal space(radiograph) Vertical or angular bone destruction Infra-bony pockets Pathologic migration (especially in anterior teeth)

24. Periodontal disease with pathologic migration of the anterior teeth

25. Sensitivity to Percussion Feature of acute inflammation of periodontal ligament. Dentition with the Jaws Closed Irregularly aligned teeth Extruded teeth Improper proximal contacts Areas of food impaction

26. Examination of the Periodontium The periodontal examination should be systematic, starting in the molar region in either the maxilla or the mandible and proceeding around the arch.

27. Plaque and Calculus The presence of supragingival plaque and calculus can be directly observed and the amount measured with a calibrated probe. For the detection of subgingival calculus, each tooth surface is carefully checked to the level of the gingival attachment with a no. 17 or no. 3A explorer.

28. Gingiva Gingiva must be dried before accurate observation can be made. Observation Exploration with instruments Firm but gentle Palpation

29. Features to consider: Color Size Contour Consistency Surface texture Position Ease of bleeding Pain

30. Clinically gingival inflammation can produce two basic types of tissue response : Edematous (smooth, glossy, red gingiva ) Fibrous (firm, stippled, opaque, thicker, round margins)

31. Periodontal Pockets Must include their presence and distribution on each tooth surface Pocket depth Level of attachment on the root Type of pocket(supra-bony, infra-bony)

32. Signs and symptoms Although probing is the only reliable method of detecting pockets, clinical signs, such as : Color changes(bluish red margin, Bluish red vertical zone) “Rolled” edge margins Enlarged edematous gingiva Bleeding Suppuration Loose, extruded teeth

33. Generally painless But localized pain and sometimes radiating pain Sensation of pressure after eating A foul taste in localized areas Sensitivity to hot and cold Toothache in absence of caries

34. Detection Of Pockets The only way is careful exploration using periodontal probe. Pocket Probing the biologic or histologic depth and (2) the clinical or probing depth

35. Probing Technique The probe should be inserted parallel to the vertical axis of the tooth and “walked” circumferentially around each surface of each tooth

36. Level of Attachment Versus Pocket Depth Pocket depth is the distance between the base of the pocket and the gingival margin The level of attachment, on the other hand, is the distance between the base of the pocket and a fixed point on the crown such as the cementoenamel junction (CEJ)

37. Amount of Attached Gingiva It is important to establish the relation between the bottom of the pocket and the mucogingival line

38. Degree of Gingival Recession This measurement is taken with a periodontal probe from the CEJ to the gingival crest, and it is drawn on the patient's chart. Alveolar Bone Loss Alveolar bone levels are evaluated by clinical and radiographic examination. Palpation Palpating the oral mucosa in the lateral and apical areas of the tooth may help locate the origin of radiating pain that the patient cannot localize.

39. Suppuration Periodontal Abscess A periodontal abscess is a localized accumulation of exudate within the gingival wall of a periodontal pocket, May be acute or chronic

40. The acute periodontal abscess An ovoid elevation of gingiva along lateral aspect of the root Gingiva is edematous and red Smooth, shiny surface

41. The acute periodontal abscess Throbbing Tenderness of gingiva to palpation Radiating pain Pain of the tooth to palpation Tooth mobility

42. The chronic periodontal abscess Presents a sinus that opens into the gingival mucosa There might be a history of intermittent exudation Orifice of the sinus is hard to detect The sinus may be covered by a small, pink, beadlike mass of granulation tissue Usually asymptomatic

43. Periodontal Abscess and Gingival Abscess The principal differences between the periodontal abscess and the gingival abscess are location and history The gingival abscess is confined to the marginal gingiva , and it often occurs in previously disease-free areas It is usually an acute inflammatory response to forcing of foreign material into the gingiva The periodontal abscess involves the supporting periodontal structures and generally occurs in the course of chronic destructive periodontitis .

44. Periodontal Abscess and Periapical Abscess If the tooth is nonvital , the lesion is most likely periapical . However, a previously nonvital tooth can have a deep periodontal pocket that can abscess. Moreover, a deep periodontal pocket can extend to the apex and cause pulpal involvement and necrosis

45. An apical abscess may spread along the lateral aspect of the root to the gingival margin However, when the apex and lateral surface of a root are involved by a single lesion that can be probed directly from the gingival margin, the lesion is more likely to have originated as a periodontal abscess A draining sinus on the lateral aspect of the root suggests periodontal rather than apical involvement

46. Laboratory Aids to Clinical Diagnosis After consulting the patient’s physician about presence of any systemic disease. Analyses of blood smears Blood cell counts White blood cell differential counts erythrocyte sedimentation rates