Clinical periodontology diagnosis part -2.pptx

Diagnostic

1. Clinical diagnosis (part-2) Examination of Periodontium Prateek Yadav Junior resident

2. Contents covered in Part-1 Introduction Overall Appraisal of the Patient Medical / Health history Photographic Documentation & Study Models Clinical Examination Extra-oral Structure Oral cavity Oral hygiene performance

3. Contents Introduction Visual Periodontal Examination Biofilm and Calculus Gingiva Apical Migration Tactile Periodontal Examination Marginal Gingiva Bleeding & Suppuration Gingival Crevice Probing Depth Determination of Disease activity Alveolar bone loss Periodontal abscess Mobility Trauma from occlusion Conclusion

4. INTRODUCTION Examination of the periodontium consists of two parts: 1.Visual examination 2.Tactile examination

5. Visual Periodontal Examination It begins with drying the tissue and taking a survey of: 1. Biofilm and calculus accumulation to assess oral hygiene 2. Gingiva to assess clinical signs of inflammation (erythema, edema, etc.) 3. Apical migration of gingival margin to assess the presence and severity of disease.

6. 1. Biofilm and Calculus The presence of biofilm and supragingival calculus can be observed directly. The amount and location of biofilm and supragingival calculus may provide insights into the effectiveness of the patient’s biofilm control as well as possible inflammatory changes in the tissue Fischman SL, Picozzi A: Review of the literature: the methodology of clinical calculus evaluation, J Periodontol 40:607, 1969.

7. Supragingival calculus tends to accumulates on the lingual surfaces of the mandibular anterior teeth and the buccal surfaces of the maxillary molars. Sometimes shallow subgingival calculus may be visible along the gingival margin or through the soft tissue if the soft tissue is thin.

8. According to Celsus (30 B.C.-38 A.D.) the 5 cardinal signs of inflammation are: redness ( rubor ) swelling (tumor) heat ( calor ) pain (dolor) loss of function ( functio laesa ) In addition to these cardinal signs, inflamed periodontal tissues may also exhibit : bleeding on probing Suppuration or gingival exudate ulceration 2. Gingiva

9. Color Changes in the Gingiva The gingiva becomes red when vascularization increases or the degree of epithelial keratinization is reduced or disappears. The color becomes pale when vascularization is reduced or epithelial keratinization increases. C hronic inflammation intensifies the red or bluish red color as a result of vascular proliferation and a reduction of keratinization. Dummett CO: Oral tissue color changes, Ala J Med Sci 16:274, 1979.

10. When the cementoenamel junction (CEJ) is supragingival , recession is the distance from the CEJ to the gingival margin. 3. Gingival Recession (Apical migration of Gingiva) The canine and first premolar exhibit gingival recession defect and minimal keratinized tissue

11. At sites with recession, the presence of bioilm and calculus, the inflammatory changes in the gingiva should be recorded and the width of the keratinized tissue and the amount of recession should be carefully evaluated.

12. Actual position of gingiva : It is the level of coronal end of epithelial attachment on the tooth. Apparent position of gingiva : It is the level of crest of gingival margin.

13. Tactile Periodontal Examination Tactile periodontal examination begins with the evaluation of the consistency of the gingiva and its adaptation to the tooth as well as the presence of marginal bleeding and suppuration . The gingival crevice is then probed to evaluate the subgingival environment. The response of the gingival tissue to probing is appraised in terms of resistance to and depth of probe penetration as well as bleeding , suppuration and pain on probing.

14. 1. Marginal Gingiva I t is palpated with a periodontal probe to assess its consistency and adaptation to the tooth. When inflamed , the gingiva is edematous, spongy, and loosely adapted to the tooth surface due to the degradation of collagen and the influx of cells and f luid into the lamina propria .

15. Marginal Bleeding Marginal bleeding can be evaluated by running an instrument such as a probe or rubber tip along the gingival margin. Under pressure, healthy gingival tissue will blanch and not bleed, whereas in the presence of gingival inflammation , marginal bleeding is triggered. The ease and severity of marginal bleeding are correlated with the actual severity of gingival inflammation .

16. Suppuration Palpation of the marginal gingiva with a probe, or digitally by placing the ball of the index f inger on the gingiva apical to the margin . Several studi es h ave evaluated the association between suppuration and the progression of periodontitis and have reported that this sign is present in a very low percentage of diseased sites (i.e., 3% to 5%) .

17. 2. Gingival Crevice The probe is inserted into the gingival crevice vertically with the tip of the probe touching and sliding down along the tooth surface to the bottom of the crevice. The probe is “walked” circumferentially around each surface of each tooth to detect the areas of deepest penetration.

18. As the probe tip slides along the tooth surface :- If t he tooth surface feel s smooth - no irregularity or subgingival calculus If the tooth surface feels rough or if the probe tip stops on a hard surface - presence of subgingival calculus should be suspected.

19. Periodontal defects tend to be associated with deep probing depths and gingival inflammation . To detect an interdental crater, the probe should be placed obliquely from both the facial and lingual surfaces to explore the deepest point of the pocket located beneath the contact point.

20. Probing Depth Biologic depth - It is the distance between the gingival margin and the base of the gingival sulcular epithelium (i.e., the coronal end of the junctional epithelium). This can be measured only in carefully prepared and adequately oriented histologic sections.

21. Clinical probing depth - It is the distance from the gingival margin to the bottom of the probeable crevice (i.e., where the probe tip stops). It is generally ≤3 mm in gingival health and >3 mm in the presence of gingival infammation . Hassel TM, German MA, Saxer UP: Periodontal probing: interinvestigator discrepancies and correlations between probing force and recorded depth, Helv Odontol Acta 17:38, 1973

22. In a normal sulcus, the probe penetrates about one-third to half the length of the junctional epithelium (between arrows). In an inflamed periodontal pocket, the probe penetrates beyond the apical end of the junctional epithelium (between arrows).

23. Bleeding on Probing The insertion of a probe to the bottom of the pocket elicits bleeding if the gingiva is inflamed and if the pocket epithelium is atrophic or ulcerated. Non inflamed sites rarely bleeds. Depending on the severity of inflammation , bleeding can vary from a tenuous red line along the gingival sulcus to profuse bleeding.

24. To test for bleeding after probing, the probe is carefully introduced to the bottom of the pocket and gently moved laterally along the pocket wall. Sometimes bleeding appears immediately after the removal of the probe; other times it may be delayed . Therefore the clinician should recheck for bleeding 30 to 60 seconds after probing.

25. Probing Force A force of 0.75 N has been found to be well tolerated and accurate. With forces of up to 30 g, the tip of the probe remains within the junctional epithelium, whereas forces of up to 50 g are necessary to reach the bone level. 32. Kalkwarf KI, Kahldal WD, Patil KD: Comparison of manual and pressure controlled periodontal probing, J Periodontol 57:467, 1986.

26. Generation of Probes B.L.PHILSTROM 1992. has described different generation of probes. 1. First generation or conventional or manual probes 2. Second generation or probes with controlled force application. 3. 3rd generation probes or automated probes. 4. 4th generation – recording sequential probe positions along gingival sulcus. 5. 5th generation – Ultrasonographic perio probe . © 2012 Int. Journal of Clinical Dental Science

27. First Generation : (Conventional or manual probes) Invented in 1936 by periodontist Charles Williams. They do not control probing pressure and are not suited for automatic data collection. Williams’ Graduated, CPITN, UNC-15, Goldman-Fox, Nabers .

28. Second Generation (Constant-Pressure) These instruments are pressure sensitive, allowing for improved standardization of probing pressure. Do not require computerization in the dental office. The true pressure sensitive probe. The indicator lines meet at a specified force of 20 gm.

29. Third Generation (Toronto Automated, Florida Probe, InterProbe, Foster-Miller ) They were developed to help minimize the mistakes by using not only standardized pressure but also digital readouts of the probes’ readings and computerized data storage. Schematic representation of various parts of the Foster-Miller probe Foster-Miller probe Perry DA, Taggart EJ, Leung A, et al: Comparison of a conventional probe with electronic and manual pressure-regulated probes, J Periodontol 65:908, 1994.

30. The main mechanism of action of the Foster-Miller probe functions is by detection of the CEJ. The ball tip moves or glides over the root surface at a controlled speed and preset pressure. Abrupt changes in the acceleration of the probe movement (recorded on a graph) indicate when it meets the CEJ and when it is stopped at the base of the pocket.

31. Fourth Generation : (Three-dimensional (3D) probes) Currently under development, these probes are aimed at recording sequential probe positions along the gingival sulcus. They attempt to extend linear probing in a serial manner to take into account the 3D pocket.

32. Fifth generation : Probes are being designed to be 3D and noninvasive Ultrasound or other device is added to a fourth-generation probe. Aim to identify the attachment level without penetrating it. Periodontal Probing Systems: A Review of Available Equipment, Compendium of continuing education in dentistry (Jamesburg, N.J.: 1995) March 2011

33. The only fifth-generation probe available, the UltraSonographic (US) probe (Visual Programs), 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. Periodontal Probing Systems: A Review of Available Equipment, Compendium of continuing education in dentistry (Jamesburg, N.J.: 1995) March 2011

34. Pain on Probing The presence of pain suggests that the gingival tissue is inflamed, and the level of pain is usually related to the severity of gingival inflammation. Unless gingival inflammation is generalized and severe, patients will not feel the sam e l evel of pain at every site.

35. Attachment Loss It is the apical migration of the dentogingival junction (DGJ)— the periodontal attachment apparatus—as a result of the inflammatory response. The DGJ consists of the epithelial attachment and the connective tissue attachment. The classic term to refer to the apicocoronal dimension of dentogingival junction is the biologic width which has been recently replaced by “ Supra crestal tissue attachment ” The dimension of supracrestal tissue averages 2.04 mm in humans.

36. Clinical attachment loss (CAL) is measured as the distance from the CEJ to the bottom of the probable crevice.

37. Attachment Level It describes the location where the DGJ begins coronally on a tooth surface . Clinical attachment loss measures the distance between the attachment level and a reference point on a tooth, such as the CEJ. Changes in the attachment level can be the result of a gain or a loss of attachment, and they can provide valuable information to make clinical decisions.

38. Shallow pockets attached at the level of the apical third of the root connote more severe destruction than deep pockets attached at the coronal third of the root. Clinical attachment loss measures how much attachment loss has occurred using the cementoenamel junction as the reference point. Clinical attachment level measures the distance between where the periodontal attachment apparatus begins coronally on a tooth and a fixed reference point.

39. Determination of Disease Activity Inactive (quiescent) lesions may show little or no bleeding with probing and minimal amounts of gingival fluid . Active lesions bleed more readily with probing and have large amounts of fluid and exudate, although active and nonactive sites may show no differences with regard to bleeding with probing, even in patients with aggressive periodontitis . Kalkwarf KI, Kahldal WD, Patil KD: Comparison of manual and pressure controlled periodontal probing, J Periodontol 57:467, 1986.

40. Alveolar Bone Loss Interproximal alveolar bone levels are primarily evaluated by radiographic examination. Probing is helpful for determining the following: 1) the height and contour of the facial and lingual bones, which are obscured on the radiograph by the roots, and 2 ) the architecture of the interdental bone Greenberg J, Laster L, Listgarten MA: Transgingival probing as a potential estimator of alveolar bone level, J Periodontol 47:514, 1976.

41. Furcation invasion Attachment loss can result in furcation invasion, the pathologic resorption of inter-radicular bone within a furcation of a multi-rooted tooth due to periodontal disease. Specialized probes, such the Nabers probe, may facilitate detection of mesial and distal furcation invasion.

42. The Glickman Classification of furcation invasion is the most commonly used, and it is : • Grade I: pocket formation into the flute but intact inter-radicular bone • Grade II: loss of inter-radicular bone and pocket formation of varying depths into the furcation but not completely through to the opposite side of the tooth • Grade III: through-and-through lesion • Grade IV: same as grade III with gingival recession, rendering the furcation clinically visible Glickman I: Clinical periodontology, ed 2, Philadelphia, 1958, W.B. Saunders, pp 694–696.

43. Periodontal abscess A periodontal abscess is a localized accumulation of exudate within the gingival wall of a periodontal pocket . Periodontal abscesses may be acute or chronic. The acute periodontal abscess appears as an ovoid elevation of the gingiva along the surface of the root. T he chronic periodontal abscess usually presents a sinus that opens onto the gingival mucosa .

44. Mobility As a general rule, mobility is graded clinically by holding the tooth firmly between the handles of two metallic instruments or with one metallic instrument and one f inger .

45. Mobility is scored according to the ease and extent of tooth movement according to the Miller Index as follows: Mobility no. 1: first distinguishable sign of movement greater than “normal” Mobility no. 2: movement of a tooth that allows the crown to move 1mm from its normal position , in any direction. Mobility no. 3:Mobility that allows a tooth to move more than 1 mm, in any direction Miller SC: Textbook of periodontia, ed 3, Philadelphia, 1950, Blackston , p 125.

46. Trauma from occlusion Trauma from occlusion refers to tissue injury produced by supra-physiologic occlusal forces. The diagnosis of trauma from occlusion is made considering the condition of the periodontal tissue, not the magnitude of force per se.

47. Radiographic signs of trauma from occlusion may include the following: 1. Increased width of the periodontal space, 2. Vertical or angular bone destruction. 3. Radiolucency and condensation of the alveolar bone. 4. Root resorption. Its Important to note t rauma from occlusion does not initiate gingivitis or periodontal pockets, but it may constitute an additional risk factor for the progression and severity of the disease.

48. Conclusion Periodontal examination begins with the acquisition of a thorough medical and dental history. A proper periodontal examination should include an overall survey of biofilm and calculus , clinical sign of inflammation and other obvious sign of disease to obtain insights into patient hygiene performance and disease status. Examination and information gathering Diagnosis Treatment Prognosis