Examination, Clinical Diagnosis

And Treatment Of Perio Diseases

 Introduction
• Periodontal treatment requires an
interrelationship
between the care of the periodontium and other
phases of dentistry.
• The concept of total treatment is based on the
elimination of gingival inflammation and the
factors that lead to it.
• Factors related to gingival inflammation

– 1.plaque accumulation that favored by calculus

and pocket formation
– 2. inadequate restorations, and
– 3. areas of food impaction.
• Total treatment requires consideration of
systemic aspects, including the possibility of
interaction of periodontal disease with other
diseases.
• Systemic adjuncts to local treatment, and special
precautions in patient management is important.
• It may also entail consideration of functional
aspects for the establishment of optimal occlusal
relationships for the entire dentition.
• A rational sequence of dental procedures
that includes periodontal and other measures
necessary to create a well-functioning
dentition in a healthy periodontal
environment should be followed.
 Clinical Diagnosis
FIRST VISIT
• Overall Appraisal of the Patient
• Medical History
• Dental History
• Intraoral Radiographic Survey
• Casts
• Clinical Photographs
• Review of the Initial Examination
SECOND VISIT
• Oral Examination
• Examination of the Teeth
• Examination of the Periodontium
• THE PERIODONTAL SCREENING AND RECORDING
SYSTEM
• LABORATORY AIDS TO CLINICAL DIAGNOSIS
– Nutritional Status
– Patients on Special Diets for Medical Reasons
– Blood Tests
 Diagnosis of Periodontal Conditions
• Proper diagnosis is essential to intelligent
treatment.
• Periodontal diagnosis should first determine
– whether disease is present
– then identify its type
– extent,
– distribution,
– and severity;
– an understanding of the underlying pathologic
processes and its cause.
In general, periodontal diagnoses fall into three
broad categories.
– The gingival diseases
– The various types of periodontitis
– The periodontal manifestations of systemic
diseases
Gingival diseases
• Periodontal diagnosis is determined after
– careful analysis of the case history
– evaluation of the clinical signs and symptoms
– Evaluation of the results of various tests (e.g.,
probing mobility assessment, radiographs, blood
tests, and biopsies)
• The interest should be in the patient who has
the disease and not simply in the disease
itself.
• Diagnosis must therefore include a general
evaluation of the patient and consideration of the
oral cavity.
• Diagnostic procedures must be systematic and
organized for specific purposes. It is not enough
to only assemble facts.
• The findings must be pieced together so that they
provide a meaningful explanation of the patient's
periodontal problem.
Recommended sequence of procedures for
the diagnosis of periodontal diseases.
FIRST VISIT
• Overall Appraisal of the Patient
– From the first meeting, the clinician should
attempt an overall appraisal of the patient.
– This includes consideration of the patient's
mental and emotional status,
temperament ,attitude, and physiologic age.
Medical History
• Most medical history is obtained in first visit
and can be supplemented by pertinent
questioning at subsequent visits.
• The health history can be obtained verbally by
questioning the patient and recording his or
her responses on a blank piece of paper or by
means of a printed questionnaire the patient
complétés.
• The patient should be made aware of
(1) the possible role that some systemic
diseases, conditions or behavioral factors may
play in the cause of periodontal disease
(2) oral infection may have a powerful
influence on the occurrence and severity of a
variety of systemic diseases and conditions.
• The medical history aids the clinician in
– the diagnosis of oral manifestations of systemic
disease
– detection of systemic conditions that may be
affecting the periodontal tissue response to local
factors
– Detection of systemic conditions that require
special precautions and/or modifications in
treatment procedures.
The medical history should include reference to:

1. Is the patient under the care of a physician and, if so,

what is the nature and duration of the problem and
the therapy? The name, address, and telephone number of the
physician should be recorded, since direct communication with
him or her may be necessary.

2. Details on hospitalization and operations, including

diagnosis, kind of operation, and untoward events
such as anesthetic, hemorrhagic, or infectious complications,
should be provided.
3. A list should be supplied of all medications being
taken and whether they were prescribed or obtained over
the counter.
- possible effects of these medications should be carefully
analyzed to determine their effect, if any, on the oral
tissues
- also to avoid administering medications that would
interact adversely with them.
- Special inquiry should be made regarding the dosage
and duration of therapy with anticoagulants and
corticosteroids.
4. History should be taken of all medical
problems (cardiovascular, hematologic,
endocrine, etc.), including infectious diseases,
sexually transmitted diseases, and high-risk
behavior for human immunodeficiency virus
(HIV) infection.
5. Any possibility of occupational disease should
be noted
6. Abnormal bleeding tendencies such as nosebleeds,
prolonged bleeding from minor cuts, spontaneous
ecchymoses, tendency toward excessive bruising, and
excessive menstrual bleeding should be cited.
7. History of allergy should be taken, including hay
fever, asthma, sensitivity to foods, or sensitivity to
drugs such as aspirin, codeine, barbiturates,
sulfonamides, antibiotics, procaine, and laxatives, to
dental materials such as eugenol or acrylic resins.
8. Information is needed regarding the onset of
puberty for females, menopause, menstrual
disorders, hysterectomy, pregnancies, and
miscarriages.
9. Family medical history should be taken,
including bleeding disorders and diabetes
Dental History
Include
• list of visits to the dentist including frequency; date of the most
recent visit; nature of the treatment; and oral prophylaxis or
cleaning by a dentist or hygienist, including frequency and date of
most recent cleaning.
• The patient's oral hygiene regimen should be noted, including
tooth brushing frequency, time of day, method, type of toothbrush
and dentifrice, and interval at which brushes are replaced.
• Other methods for mouth care, such as mouthwashes, finger
massage, interdental stimulation, water irrigation, and dental floss.
• What are the patient's general dental habits?
– If there is any grinding or clenching of the teeth during the
day or at night.
– Do the teeth or jaw muscles feel "sore" in the morning?
– Are there other habits, such as tobacco smoking or chewing,
nail biting, or biting on foreign objects?
• History of previous periodontal problems should be
noted, including the nature of the condition and, if
previously treated, the type of treatment received
(surgical or nonsurgical) and approximate period of
termination of previous treatment.
• If, in the opinion of the patient, the present
problem is a recurrence of previous disease,
what does he or she think caused it?
Intraoral Radiographic Survey
• The radiographic survey should consist of a
minimum of 14 intraoral films and four posterior
bite-wing films
• 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.
• They provide an informative overall
radiographic picture of the distribution and
severity of bone destruction in periodontal
disease, but a complete intraoral series is
required for periodontal diagnosis and
treatment planning. .
Casts
• Casts from dental impressions are extremely useful adjuncts in
the oral examination.
• They indicate the position of the gingival margins and the
position and inclination of the teeth, proximal contact
relationships, and food impaction areas. In addition, they
provide a view of lingual-cuspal relationships.
• They are important records of the dentition before it is altered
by treatment.
• Finally, casts also serve as visual aids in discussions with the
patient and are useful for pre- and post-treatment
comparisons, as well as for reference at checkup visits
Clinical Photographs
• Color photographs are not essential, but they
are useful for recording the appearance of the
tissue before and after treatment.
• Photographs cannot always be relied on for
comparing subtle color changes in the gingiva,
but they do depict gingival morphologic
changes
• Review of the Initial Examination
– I f no emergency care is required, the patient is
dismissed and
– instructed as to when to report for the second
visit.
SECOND VISIT
Oral Examination
– Oral Hygiene. The cleanliness of the oral cavity is
appraised in terms of the extent of accumulated
food debris, plaque, materia alba, and tooth
surface stains .
– Disclosing solution may be used to detect plaque
that would otherwise be unnoticed.
– The amount of plaque detected, however, is not
necessarily related to the severity of the disease
present.
– For example, aggressive periodontitis is a
destructive type of periodontitis in which plaque is
scanty.
– Qualitative assessments of plaque are more
meaningful.
Mouth Odors.
• Termed as halitosis, also termed fetor ex ore,
fetor oris, and oral malodor,
• is foul or offensive odor emanating from the
oral cavity.
• Mouth odors may be of diagnostic
significance, and their origin may be either
oral or extraoral (remote).
• Halitosis is caused primarily by volatile sulfur
compounds, specifically, hydrogen sulfide and
methyl mercaptan, which result from the
bacterial putrefaction of proteins containing
sulfur amino acids.
• These products could be involved in the
transition from health to gingivitis and then to
periodontitis.
• Local sources of mouth odors are mainly the
– tongue and the gingival
– retention of odoriferous food particles on and between the
teeth
– coated tongue,
– necrotizing ulcerative gingivitis (NUG),
– dehydration states,
– caries,
– artificial dentures,
– smoker's breath,
– and healing surgical or extraction wounds.
• The fetid odor that is a characteristic of NUG
is easily identified.
• Chronic periodontitis with pocket formation
may also cause unpleasant mouth odor from
any accumulated debris and the increased rate
of putrefaction of the saliva
• Extraoral sources of mouth odors include various
infections
or lesions of
– the respiratory tract (bronchitis, pneumonia, bronchiectasis,
or others) and
– odors that are excreted through the lungs from aromatic
substances in the bloodstream, such as metabolites from
ingested foods or excretory products of cell metabolism.
– Alcoholic breath,
– the acetone odor of diabetes,
– and the uremic breath that accompanies kidney dysfunction.
Examination of the Oral Cavity.
• The entire oral cavity should be carefully examined.
• The examination should include the lips, floor of
the mouth, tongue, palate, and oropharyngeal
region, as well as the quality and quantity of saliva.
• Although findings may not be related to the
periodontal problem, they should enable the
dentist to detect any pathologic changes present in
the mouth.
Examination of Lymph Nodes.
• Because periodontal, periapical, and other oral
diseases may result in lymph node changes, the
diagnostician should routinely examine and
evaluate head and neck lymph nodes.
• Lymph nodes can become enlarged and/or
indurated as a result of an infectious episode,
malignant metastases, or residual fibrotic
changes.
• Inflammatory nodes become enlarged, palpable,
tender, and fairly immobile.
• The overlying skin may be red and warm. Patients
are often aware of the presence of "swollen
glands.“
• Primary herpetic gingivostomatitis, NUG, and acute
periodontal abscesses may produce lymph node
enlargement.
• After successful therapy, lymph nodes return to
normal in a matter of days or a few weeks.
Examination of the Teeth
• The teeth are examined for caries, developmental
defects,
anomalies of tooth form, wasting, hypersensitivity, and
proximal contact relationships.
• Wasting Disease of the Teeth. Wasting is defined as any
gradual loss o f tooth substance characterized by the
formation of smooth, polished surfaces, without regard
to the possible mechanism of this loss. The forms of
wasting are erosion, abrasion, and attrition.
Erosion
• Erosion (cuneiform defect) is a sharply defined
wedge-shaped depression in the cervical area of the
facial
tooth surface.
• The long axis of the eroded area is perpendicular to the
vertical axis of the tooth.
• The surfaces are smooth, hard, and polished. Erosion
generally affects a group of teeth. In the early stages, it
may be confined to the enamel, but it generally extends to
involve the underlying dentin as well as the cementum.
• The cause of erosion is not known.
Decalcification by acid beverages or citrus
fruits, along with the combined effect of acid
salivary secretion and friction are suggested
causes.
Abrasion
• Abrasion refers to the loss of tooth substance induced
by mechanical wear other than that of mastication.
• Abrasion results in saucer-shaped or wedge-shaped
indentations with a smooth, shiny surface.
• Abrasion starts on exposed cementum surfaces rather than
on the enamel and extends to involve the dentin of the root.
• A sharp "ditching" around the cementoenamel junction
appears due to the softer cemental surface, as compared
with the much harder enamel surface.
Erosion
Abrasion
Dental Stains.
• These are pigmented deposits on the teeth.
They should be carefully examined to
determine their origin.
• Extrinsic Vs Intrinsic stains
Hypersensitivity.
• Root surfaces exposed by gingival recession
may be hypersensitive to thermal changes or
tactile stimulation.
• Patients often direct the operator to the
sensitive areas. These may be located by
gentle exploration with a probe or cold air.
Proximal Contact Relations.
• Slightly open contacts permit food impaction.
• The tightness of contacts should be checked by means
of clinical observation and with dental floss
• Abnormal contact relationships may also initiate
occlusal changes such as a shift in the median line
between the central incisors, labial version of the
maxillary canine, buccal or lingual displacement
of the posterior teeth, and an uneven relationship
of the marginal ridges.
Cheking contact point
Tooth Mobility.
• All teeth have a slight degree of physiologic
mobility, which varies for different teeth and at
different times of the day.“
• It is greatest on arising in the morning and
progressively decreases.
• The increased mobility in the morning is
attributed to slight extrusion of the tooth because
of limited occlusal contact during sleep. .
• During the waking hours, mobility is reduced
by chewing and swallowing forces, which
intrude the teeth in the sockets.
• These 24-hour variations are less marked
in persons with a healthy periodontium than
in those with occlusal habits such as bruxism
and clenching
• Single-rooted teeth have more mobility than
multirooted teeth, with incisors having the
most.
• Mobility is principally in a horizontal direction,
although some axial mobility occurs, to a
much lesser degree.
Tooth mobility occurs in two stages:
1. The initial or intrasocket stage is where the tooth
moves within the confines of the periodontal
ligament.
– This is associated with viscoelastic distortion of the
ligament and redistribution of the periodontal
fluids,interbundle content, and fibers .
– This initial movement occurs with forces of about 100
lb and is of the order of 0.05 to 0.10 mm (50 to 100
microns
2. The secondary stage
– occurs gradually and entails elastic deformation
of the alveolar bone in response to increased
horizontal forces.
– When a force of 500 Ibs is applied to the crown,
the resulting displacement is about 100 to 200
microns for incisors, 50 to 90 microns for canines,
8 to 10 microns for premolars, and 40 to 80
microns for molars .
• Mobility is graded according to the ease and
extent of tooth movement as follows
– 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.
• Mobility beyond the physiologic range is
termed abnormal or pathologic.
• It is pathologic in that it exceeds the limits of
normal mobility values
• the periodontium is not necessarily diseased
at the time of examination.
• Increased mobility is caused by one or more of
the following factors:
• Loss of tooth support
– severity and distribution of bone loss
• Trauma from occlusion
– (i.e., injury produced by excessive occlusal forces
or incurred because of abnormal occlusal habits
such as bruxism and clenching) Mobility is also
increased by hypofunction.
• Extension of inflammation from the gingiva or
from theperiapex into the periodontal
ligament results in changesthat increase
mobility.
• Periodontal surgery temporarily increases
tooth mobility for a short period
• Tooth mobility is increased in pregnancy and is
sometimes associated with the menstrual cycle or
the use o f hormonal contraceptives.
– It occurs in patients with or without periodontal
disease, presumably because of physicochemical
changes in the periodontal tissues
• Pathologic processes of the jaws that destroy the
alveolar bone and/or the roots o f the teeth can
also result in mobility.
– Osteomyelitis and tumors of the jaw
Probing depth recession and mobility
Periodontal pocket
• A Periodontal probe
especially designed for the
PSR system.
• Note the ball tip and the
color coding, 3.5 to 5.5 mm
from
the probe tip.
B, Special sticker to be
placed in the patient's chart
with the code for each
sextant. (From the American
Dental Association