Examining for Periodontal Disease

These clinical strategies will help reveal pathology in its early or advanced stages
Inflammatory periodontal disease ranks among the most common chronic infections in
humans.1 These infections are responsible for a large percentage of tooth loss in adults. 2 In
addition, the ubiquity and recurrence of periodontal disease, and the damage it causes,
require frequent examinations to prevent — and, when indicated, treat — these conditions.
Examining and recording data on the state of the periodontium should therefore be an
integral part of the routine information gathered on every dentate patient. The emphasis of
this article is on what constitutes an appropriate periodontal examination, the timing and
extent of data collection, and how clinicians can determine end points in therapy based on
this information.

The severity and course of periodontal disease can be profoundly affected by the patient’s
systemic health. There is also accumulating evidence that chronic infections of all types,
including periodontal conditions, can have negative systemic health effects. 3 Therefore,
gathering information on the patient’s overall health is an integral part of the clinical data.
Questions about smoking and diabetes are especially important because both are
significant risk factors for periodontal disease. 4,5 Medications currently taken, along with
drug allergies, should also be recorded. Additional medical history data should include
demographics and familial medical/dental history, as well as baseline vitals, height and
weight. Any unanswered questions related to the patient’s systemic health should be
addressed in writing to the individual’s physician.

An overview of the head and neck, including muscles of mastication, the

temporomandibular joints and an examination for any inappropriate extraoral findings,
should be performed. This is followed by an intraoral examination designed to identify and
record any abnormalities.

BEHAVIORAL CHANGES
If periodontal disease is present, the goal of therapy is restoring health and function to
these tissues. Because these conditions are chronic and the oral biofilm responsible for
their initiation constantly returns, patient motivation to remove biofilm on a daily basis is
vitally important. This can require significant behavioral changes on the patient’s part.
These changes are difficult to initiate and even harder to sustain. In addition, it should be
understood that the patient’s desires and goals might not always be aligned with those of
the dental provider. Thus, it is important for clinicians to understand the patient’s concerns
and goals.

Treatment therefore begins with listening to the patient, as he or she will usually provide
information that is key to motivating behavioral change needed to control periodontal
disease. This can also help the provider understand the degree of knowledge that the
patient has concerning the disease process. Patients are more likely to undergo positive
behavioral changes that are designed to help them solve current problems and reach their
goals. In most cases, providing detailed information concerning the nature of the disease,
possible therapeutic alternatives, and how they benefit the patient, will help instigate and
sustain positive behavioral changes.

BASELINE MEASUREMENTS
In periodontal therapy, it is important to collect data to establish a baseline. This material
will help clinicians decide what initial treatment is appropriate and also can be used to
judge the patient’s response to therapy. The following is a list of examination parameters
that will provide adequate evidence about the patient’s periodontal status to make an initial
diagnosis and develop a treatment plan.

A full mouth series of periapical radiographs and posterior vertical bitewings are preferred
to a panoramic radiograph with horizontal bitewings, as periapical radiographs exposed at
right angles to the teeth provide more accurate and detailed information on the position of
the interproximal bone. As opposed to horizontal bitewings, the use of vertical posterior
bitewings is suggested because these films provide more accurate information concerning
interproximal bone loss and the relationship of the crest of the alveolar bone to the
cementoenamel junction (CEJ). When evaluating these films, it should be remembered that
the interproximal crest of bone is normally 2 mm apical to the CEJ. Any abnormalities or
anatomical anomalies should be recorded. 6

A count of missing teeth, as well as their replacements, should be recorded; this includes
any supernumerary or retained deciduous teeth. A search for improper tooth-to-tooth
relations, tilted, rotated or supra-erupted teeth is necessary, as these malpositions can lead
to biofilm retention and subsequent periodontal problems. These abnormalities should be
recorded and eliminated whenever possible.
Open or irregular interproximal contacts, marginal ridge discrepancies, plunger cusps and
similar conditions can lead to food impaction and subsequent bone loss, and should be
addressed. The genesis of these problems is often occlusal. Accordingly, appropriate
evaluation and subsequent elimination of these problems can help reduce future bone loss.

Occlusal abnormalities, including wear facets (which can also indicate occlusal trauma),
should be evaluated. A general examination of occlusion — including the distance between
centric relation (CR) and centric occlusion, as well as which teeth occlude in working
excursions — is a key step. In addition, identifying Angle’s malocclusion is helpful in
diagnosis and treatment planning.

Compared to teeth without such contacts, Harrel and Nunn7 have shown that premature
contacts in CR and nonworking occlusal contacts can increase periodontal attachment loss
over time. These findings may suggest the need for occlusal adjustment and/or fabrication
of habit devices (such as night guards) for patients being treated for periodontal disease.

BIDIGITAL TOOTH MOBILITY

Bidigital tooth mobility is measured using the nonworking ends of a dental mirror and
periodontal probe. A common quantitation of mobility involves a modification of the Miller
scale, as recommended by Fleszar et al 8 (Figure 1).

 Class 0: physiologic mobility; firm tooth

 Class I: Slightly increased mobility

 Class II: Definite-to-considerable increase in mobility, but no impairment of

function

 Class III: Extreme mobility; a loose tooth that would be uncomfortable in

function

It should be noted the use of this scale can result in a great deal of variation between
individual examiners, as well as between offices; with practice, however, a degree of
reproducibility can be found. And while considerable controversy exists, most practitioners
would suggest the longevity of a tooth that is stable is greater than one that is mobile.
FIGURE 1. The nonworking ends of two instruments are being used to measure bidigital
tooth mobility.

FREMITUS
Fremitus is defined as tooth movement during function, and there are two ways to measure
this parameter. The first is visual. The patient is asked to tap his or her teeth together, and
grind from side to side as pressure from the clinician’s hand keeps the teeth in contact. Any
tooth movement seen is fremitus. The second method is tactility. The clinician’s fingers are
placed on the facial aspect of the teeth in the maxillary arch, and the patient is instructed to
hold the teeth tightly together and guided in excursive movements under pressure. Any
tooth movement is fremitus. The authors have found that many hypersensitive teeth have
fremitus, and that sensitivity is ameliorated following elimination of this parameter using
selective occlusal adjustment.

SULCUS/POCKET PROBING DEPTHS

Recording pocket probing depths around each tooth is a requisite during a periodontal
examination. Six readings are taken around each tooth. A periodontal probe of 1-mm
diameter with Williams or North Carolina markings is suggested, as is a probing force of 15
Newtons (15.30 grams). With practice, reproducible measurements can be obtained. Pocket
probing depths of 1 to 3 mm are considered normal. This assumes the margins of the
gingival tissues are at their normal level; that is, slightly coronal to the CEJ (Figure 2).
Any bleeding seen within 10 to 15 seconds after removing the probe from the pocket should
be recorded. Studies have shown that absence of bleeding on probing indicates that a state
of health will usually continue for several months after the examination. 9 Although the
significance of bleeding on probing in terms of disease progression is still not completely
understood, as previously stated, recent data suggest that chronic inflammation of all types,
including periodontal disease, can negatively affect systemic health. 3 By extension, this
indicates that collection of probing data is appropriate. This is because bleeding on probing
is generally considered a sign of inflammation. Reduction or elimination of bleeding should
be a key goal of therapy.

GINGIVAL RECESSION
During the periodontal examination, buccal, lingual and interproximal tissue heights should
recorded at a fixed point (usually the CEJ or the margin of a restoration). Recession is
recorded as positive when the gingival margin is located apical to the CEJ, and as negative
when tissue is above the CEJ (Figure 2).

FIGURE 2. As seen here, pocket

probing depth is 2 mm. Recession, as measured from the cementoenamel junction to the
free gingival margin, is +3 mm. In this example, the clinical attachment level (defined as
probing depth plus recession) is 5 mm.

KERATINIZED AND ATTACHED GINGIVA

There is evidence that it is not absolutely necessary to have attached gingiva around teeth
to maintain health. However, clinical experience has shown there is less recession where
there is 1 to 2 mm of attached gingiva

Normal gingival tissue is firm and stippled. The coronoapical dimension width of the
keratinized gingiva is measured on the midfacial and midlingual of the free gingival margin
to the mucogingival junction. The amount of attached gingiva is determined by subtracting
the pocket probing depth from the amount of keratinized gingiva. The facial and lingual
dimension of this tissue should be recorded for each tooth (Figure 3).

FIGURE 3.The amount of keratinized

gingiva is measured from the free gingival margin to the mucogingival junction (illustrated
by the yellow probe). This example shows 6 mm of keratinized gingiva. The probing depth
on the facial is 2 mm, indicating 4 mm of attached gingiva. The North Carolina markings are
featured on the yellow plastic probe, while the Williams markings are seen on the metal
probe.

CLINICAL ATTACHMENT LEVEL

Clinical attachment level (CAL) is calculated by adding pocket probing depth to the amount
of recession in each area around the tooth. These data points provide a more accurate
representation of the amount of attachment loss around each surface of each tooth than
probing depth alone. It is possible to have probing depths within normal range (1 to 3 mm),
for example, and yet have CAL recordings of 10 to 12 mm, indicating very little attachment
remaining around that surface of the tooth.
INITIAL DIAGNOSIS AND TREATMENT
At this point, an initial diagnosis is made. The options are health, gingivitis or periodontitis.
Health is defined as no history of clinical attachment loss and no signs of inflammation.
Gingivitis can be defined as probing depths of 1 to 3 mm with no history of attachment loss,
but associated with clinical signs of inflammation — including color changes toward red
and bleeding on probing. Periodontitis is defined as probing depths of 4 mm or greater,
accompanied by clinical signs of inflammation in areas without gingival hypertrophy. The
process is defined histologically by a loss of periodontal attachment apparatus (cementum,
periodontal ligament and alveolar bone), resulting in an apical shift of the junctional
epithelium and connective tissue attachment.10 While most patients with periodontitis have
the chronic form, an aggressive form of this disease — characterized by rapid loss of
attachment — can be seen in some individuals. This often presents in young patients and
should be referred to a specialist. Notably, specific classifications of periodontal disease
have been updated recently by the American Academy of Periodontology task force
regarding CAL, localized versus generalized periodontitis, and chronic versus aggressive
periodontitis.11

Treatment of these chronic infections includes appropriate instruction in personal hygiene

and clinical removal of local factors (including supra- and subgingival calculus and biofilm).
Any appropriate initial occlusal therapy is performed at this stage. Following treatment, a
reevaluation of the patient’s periodontal status is necessary. Residual signs of active
chronic periodontitis often require surgical intervention. In fact, aggressive periodontitis
often responds best to surgical therapy.

END POINTS AND MAINTENANCE

Ideal end points of periodontal therapy include probing depths of 3 mm or less, no clinical
signs of inflammation (e.g., no bleeding on probing), the margin of the soft tissues at or
slightly occlusal to the CEJ, and functional tooth mobility. Realistic endpoints include
minimal signs of inflammation as evidenced by reduced bleeding on probing (10% of sites
or fewer), and probing depths and teeth that are stable over time. Failure to reach these
endpoints should warrant reevaluation and further treatment until the periodontium is
stable. If deeper probing depths remain or inflammation continues, surgery to regenerate
periodontal attachment may be indicated.
Once a patient’s end points are stable, a final diagnosis is made and this will determine
maintenance intervals. Individuals with a diagnosis of health (i.e., no attachment loss or
gingivitis) can normally be seen once a year for supportive periodontal therapy. Individuals
with a final diagnosis of gingivitis usually respond well to supportive periodontal therapy
twice per year, while patients with a final diagnosis of periodontitis typically require
maintenance visits three to four times a year. More aggressive forms of this disease, of
course, will require more frequent maintenance intervals. 12

KEY TAKEAWAYS

 Examining and recording data on the state of the periodontium should be an

integral part of the routine information gathered on every dentate patient.

 When recording health histories, questions about smoking and diabetes are
especially important because these are significant risk factors for periodontal
disease.

 Treatment begins with listening to the patient, as he or she will usually

provide information that is key to motivating the behavioral change needed to control
periodontal disease.

 Bleeding on probing is generally considered a sign of inflammation, and

reduction or elimination of bleeding should be one goal of therapy.

 Ideal end points of periodontal therapy include probing depths of 3 mm or

less, no clinical signs of inflammation, the margin of the soft tissues at or slightly
occlusal to the cementoenamel junction, and functional tooth mobility.

REFERENCES

1. U.S. Department of Health and Human Services. National Center for Health
Statistics. Third National Health and Nutrition Examination Survey, NHANES III
Examination Data File. Available at:
wwwn.cdc.gov/nchs/data/nhanes3/1a/readme.txt. Accessed April 17, 2017.
2. Akhter R, Hassan NM, Aida J, Zaman KU, Morita M. Risk indicators for tooth
loss due to caries and periodontal disease in recipients of free dental treatment in an
adult population in Bangladesh. Oral Health Prev Dent. 2008;6:199–207.

3. Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ. Prevalence of
periodontitis in adults in the United States: 2009 and 2010. J Dent Res.
2012;91:914–920.

4. Mealey BL, Oates TW, American Academy of Periodontology. Diabetes

mellitus and periodontal diseases. J Periodontol. 2006;77:1289–1303.

5. Rivera-Hidalgo F. Smoking and periodontal disease: a review of the literature.

J Periodontol. 1986;57:617–624.

6. Tugnait A, Clerehugh V, Hirschmann PN. The usefulness of radiographs in

diagnosis and management of periodontal diseases: a review. J Dent. 2000;28:219–
226.

7. Harrel SK, Nunn ME. The association of occlusal contacts with the presence
of increased periodontal probing depth. J Clin Periodontol. 2009;36:1035–1042.

8. Fleszar TJ, Knowles JW, Morrison EC, Burgett FG, Nissle RR, Ramfjord SP.
Tooth mobility and periodontal therapy. J Clin Periodontol. 1980;7:495–505.

9. Lang NP, Adler R, Joss A, Nyman, S. Absence of bleeding on probing an

indicator of periodontal stability. J Clin Periodontol. 1990;17:714–721.

10. Page RC, Schroeder HE. Pathogenesis of inflammatory periodontal disease. A

summary of current work. Lab Invest. 1976;34:235–249.

11. American Academy of Periodontology. Task force report on the update to the
1999 classification of periodontal diseases and conditions. J Periodontal.
2015;86:835–838.

12. Cohen RE, Research, Science and Therapy Committee, American Academy of
Periodontology. Position paper: periodontal maintenance. J
Periodontal. 2003;74:1395–1401.
The authors have no commercial conflicts of interest to disclose.

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From Decisions in Dentistry. May 2017;3(5):11–14.