‫ﺑﺴﻢ اﷲ اﻟﺮﺣﻤﻦ اﻟﺮﺣﻴﻢ‬

I wrote this lec. without slides so I advise u to have a copy while u reading it

The unique thing about perio patients (pt) that they come to clinic
without pain, they usually refer to periodontist from other dentists
without knowing the reasons or what's happening to their gingival.
Our- duty as dentists to treat the pts and giving them many advises
to keep their gingiva in a health way because:
The health of gingiva is the health of the teeth
I mean:
Nice teeth = nice gingival that reflect our beauty.

And this needs a well trained to make a complete check up and

decide what the treatment plan is.

The Dr. here showing us a picture for a normal gingival (plz refer to
slide but I don't know the page #) its pink in color, scalloped shape (knife
shape edge), no swelling
A student said it's stippled….although it’s a normal feature but we
can't noticed it by looking at a picture.
Now about the signs of inflamed gingival:
Pain, swelling, and bleeding.

Comprehensive periodontal examination

• Medical history ( M.H )

• Dental history ( D.H )
What's the importance of M.H?

HIV pts??? Can a pt that comes to ur clinic tells u that he has a

virus or a disease like this???
Of course not so how can we know or discover these pts?

By talking with them because we can't force pts to do blood test.

Other common diseases that we should be careful during examine

pts is diabetic mellitus and comma one of its complication (the dr. told
us that it's our problem to know the information about this topic) and a cardiac
disease (a pts who have a problems in heart valves)
………………………………………..
…………………………………………

After making a M.H we remove to D.H

We have 2 types pf pt:
Regular that visit dentists continuously for check up
Irregular those only visit dentists when they have pain!!!!

Extra oral examination

• Skin
• Lymph-nodes
• Muscles

Intra oral procedures and data:

Recording / visual (gathering data to understand what's going on to

the pt)

‫ﻳﻌﻨﻲ ﻣﻨﺎﺧﺪ ﻗﺮاءات ﻟﻠﻤﺮﻳﺾ ﻷﻧﻪ ﻣﻤﻜﻦ ﻃﺒﻴﺐ اﻷﺳﻨﺎن ﻳﻔﺤﺺ اﻟﻤﺮﻳﺾ ﻣﻦ دون ﻣﺎ‬
‫ﻳﺸﻮﻓﻪ ﻳﻌﻨﻲ ﺑﺲ ﻳﺴﺄﻟﻪ أﺳﺌﻠﺔ وﺑﻌﺪﻳﻦ ﺣﻴﻴﺠﻲ اﻟﻄﺎﻟﺐ ﻳﻘﺮأ آﻞ هﺪﻟﻮل اﻟﻤﻌﻠﻮﻣﺎت أدام‬
. ‫اﻟﺪآﺘﻮر اﻟﻤﺴﺆول ﻋﻨﻪ ﺑﺲ ﻻزم ﻳﻌﻄﻴﻪ ﻓﻜﺮة ﺷﺎﻣﻠﺔ وﺑﻌﺪﻳﻦ ﻳﺤﻜﻮا ﻋﻦ ﺧﻄﺔ اﻟﻌﻼج‬
 Plz refer to slides here I think there is more talking .

What are the reasons NOT to have enough keratinized gingiva:

1. The vestibule is shallow

2. Caries
3. Agenda
4. Smoking
5. Toothbrush
6. Occlusion trauma
7. Buccal frenum (high attachment may make gingival
stretching and recession).

The most important thing we should know in perio course is the

instrumentation

Periodontal probe for pocket depth which has multiple variations in

their graduation .
It may be graduated as 3, 5, and 7
William probe that we use 1,2,3,5,7,8,9

Evaluation procedures: it means read-tissue and assess anything

like color, texture and if we have edema, bleeding (red spots on a
pocket), exudates (E) a pus on the apex of the inflamed root.

Pocket depth (PD):

Distance between gingival margin (G.M) and the depth of craves sulcus
Either the G.M on the gingiva or incisal 1/3 we should step around the tooth
from side to side...

I wrote the way in my words cz the record here was so bad

Try that the insertion of PD probe in the gingival sulcus or PD pocket between
the surface of the tooth and gingival to be parallel to the long axis of the tooth
because as you change the angulations of it: the reading will change.
The way that we measure the probing depth is walking method, insert the
probe at distal surface and move it until reach the mesial surface without
removing it from the sulcus(walking ) and I record the deepest point

‫ﻷﻧﻪ ﻣﻤﻜﻦ اﻟﺒﺮوب ﻳﻜﻮن ﻣﺎﺷﻲ ﻣﻌﻚ ﻣﻦ ﻧﺺ اﻟﺴﻦ ﺑﺲ ﻳﺪﺋﺮ ﻣﻌﻚ ﻋﻠﻰ اﻟﻄﺮف‬
So just we want to know how much gingival de attached from the tooth
We enter the probe which is already divided into parts

If we get a reading 5-6 mm we prefer to take 6 mm (always take the deepest

point)
To be more careful in treatment plane

Note:
The healthy M.G is 2 mm from cemento enamel junction coronally but if we
have M.G below CEJ we call it recession (it’s a repetition I know)...

PD is not reflecting a real disease

mm ٤ ‫ ازا آﺎن اآﺘﺮ ﻣﻦ‬P ‫ﻧﺤﻨﺎ ﺑﺎﻟﻌﻴﺎدة ﺣﻜﺘﻠﻨﺎ اﻟﺪآﺘﻮرة ﻋﺎدة ﻣﻨﻌﺘﺒﺮ ﻓﻴﻪ ﻋﻨﺎ‬
But as beginners we score any reading we get it...
The only thing that reflects a real disease is CAL

What's CAL ?

Its clinical attachment level measured by perio probe from CEJ to gingival
sulcus (I think it means the loss of attachment)

The probing depth is not reliable to determine if there is attachment loss

because the reference point in measuring it is a soft tissue which is not
fixed (ex: if it is inflamed it will be enlarged and got higher position and
when it heals it will return to lower position so we need fixed position to
measure the attachment so we depend on the measurement of clinical
attachment level CAL).

3 cases:

1. When we have a recession:

CAL = PD + recession
Gingival recession is the distance b/w CEJ and gingival margin .
2. When we have over growth
CAL = PD – space coronally to CEJ

3. G.M coincide with the CEJ :

PD = CAL

Here the Dr. shows us an examination form that we will use in perio course:

Some notes:
• About M .H we concern about smoking and the dentist can
persuade the smokers to leave this habit more than the general
doctors in medicine

• About the way that the pt brush his teeth and if he is doing that
in a wrong way we should advise him.
Auxiliary aid: I mean flossing and brushing because the tooth-
brush can't reach all the surfaces in the tooth so it's better to do
flossing.

Periodontal disease is the disease that affects the periodontium and

the majority of them are inflammatory periodontal disease which
means that the initiating factor or cause of this disease is bacteria
which are present in the dental plaque. So the first enemy that we
are facing here is the PLAQUE.

Accumulation of dental plaque the product of

bacteria lead to the inflammatory process and the
progression of these inflammatory process might cause more
destruction in periodontium including PDL,alveolar bone, forming
true pocket and t this disease stage we call it periodontitis but at the
beginning of inflammation when it is confined to gingival we call it
gingivitis.
more progression
So gingivitis periodontitis
And here the Dr started talking 3 minuets about some medicine
information; I didn’t hear clear but the general idea is the perio
disease like a chronic disease, its multi-factorial reasons and has a
relation with a growth factors, IL, and c-creative protein which is a
protein build up in liver and activate a complement system to
facilitate the phagocytes process.….

To be continued…………….

Done By:

Aseel Aref Al-Momani

The second part of the lecture….
Done by: Abdullah t. Al-Halhouli.

• The gingival index(GI) was developed by Low and Silness

1963 to describe the clinical severity of gingival inflammation as
well as its location.
-The GI depend mainly on bleeding so we pass the probe on the
marginal gingiva and see if that cause bleeding or changing in the
color of the gingiva.
-The GI describe the clinical changes not the histological one
because the normal flora of the oral cavity cause neutrophil infiltration
to gingival tissue But it could be clinically healthy.

Points Appearance Bleeding Inflammation

0 Normal No bleeding none
1 Slight change in color No bleeding mild
and mild
Edema with slight
change in texture
2 Redness Bleeding on moderate
,hypertrophy ,edema probing/pressure
and glazing
3 Marked redness Spontaneous Severe
,hypertrophy , bleeding
Edema ,ulceration

Notes:
1. Spontaneous bleeding : it is the bleeding that happened when
the patient eat or touch his gingiva so it is not sever bleeding.
2. If patient come to your clinic and he is smoker,( PD>3)and his
teeth are mobile and furcational involved but there is no
bleeding on probing we called this Masking. This happened
because smoking effect the vascularity and cause tissue
ischaemia.
3. The gingiva clinically health only when GI=0.
4. Measuring probing depth clinically by stepping around the
tooth.
• CAL(Clinical Attachment Level): measured by perio- probe
from the cemento-enamel junction(CEJ) to the bottom of the
periodontal pocket or gingival sulcus.
-The measurement of CAL depend on the gingival margin position
which could be:
1. Enlarged(over growth):the gingival margin is coronal to the
CEJ. (CAL=PD – over growth)
2. Normal. (CAL= PD)
3. Recession: the gingival margin is apical to CEJ.
(CAL =PD + gingival recession)
-For example if a site has 2mm of recession and PD=5
CAL=7mm(5mm+2mm),But if the gingival margin is located 2mm
coronal to CEJ and 5mm PD is present CAL=3mm(5mm-2mm).
Notes:
1. We use the probe to push away the gingival from the tooth to
see the CEJ so you have to know the anatomy of the tooth.
2. In class 5 restoration the base of restoration will be your
landmarks because the restoration invade the CEJ.

• Limitation of probing:
1. Angle: you step around the tooth according to it is
anatomy. In page 5 the upper left slide you can see that
when the probe away from the root the crestal bone
prevent the probe to reach the full pocket depth.
2. The force(pressure): minimum force=25gram (perfect)
maximum force = 75 gram.
3. Diameter and shape of probe tip: it should be pointed and
its diameter=0.5mm
4. Tissue inflammation: the inflammation cause overgrowth
and swelling of gingival margin(deep PD).After healing of
inflammation PD decrease.
5. Visible reference points: probing of the anterior teeth
easer than the posterior teeth.
• Intraoral procedures data recording:
-Sounding(Transgingival probing): using the probe to know the
thickness of gingiva by this we know where is the bone, we do
sounding when we do implantation.
The thick of gingiva= (1.5 mm - 3 mm) and it could be( 5 mm) if there
is tooth extraction.
• Furcation Examination:
-We use Nabors probe to do this examination which is curved and
more pointed.
Glickman system to classify furcation involvement:
- Class 1 : Incipient lesion.
- Class 2 : Bone destroyed on one or more aspects of furca,
partial penetration of probe into furcation.(the
probe doesn’t pass from buccal to lingual)
- Class 3 : Interradicular bone absent but orifice of furca is
occluded by gingival.(the probe pass from
buccal to lingual)
- Class 4 : Furca opening visible.
Note:
-In class 1,2 and 3 the gingiva cover the furca opening but in class 4
it is not.
• Explorer : which we use in conservative clinic for:
1. Caries.
2. Restorative margins.
3. Calculus.
• Mobility:
Methods to measure mobility:
1. Handles of two hard instruments(Probe & Mirror).
2. Handle of one hard instrument and one finger(Thumb).
-The mobility could be BL,MD & vertical.
Miller Mobility Index:
- Class 0 : no mobility greater than normal physiological
mobility.
- Class 1 : the first distinguishable sign of movement greater
than normal.
- Class 2 : movement of the crown up to 1mm this movement
could be BL & MD but not vertical depression movement.
- Class 3 : movement of the crown more than 1mm in any
direction and/or vertical depression or rotation of the crown in
its socket(Hypermobility).

• Occlusal Evaluation:
If there is high restoration it will cause occlusal truma ,widening to
PDL and bone loss, we should improve the occlusion.
-occlusal truma without plaque will not cause socket or PDL disease.

• Interpretation of radiographic feature:

-The best film is the vertical bitewings.
-periapical radiograph to see the apex and all the anatomy of the
tooth and if the tooth pulp involved or not.
Limitation of radiograph:
1. Exposure.
2. Angulation.
3. Processing.
4. Film position and film type.
5. Projection geometry.
6. overlapping structure(Bone & Teeth).
7. Assumption made in interpretation of images of osseous
structures.
-the distance from CEJ to bone crest in health = (1mm – 2mm)

Type and number of radiographs needed:

1. Panograph and vertical bitewings for gingivitis and slight
periodontitis.
-we do two vertical bitewing radiographs and periapical radiograph
for anterior teeth, but in other country they do full CMS for all the
teeth.
2. CMS with vertical bitewing radiographs for moderate and
severe.
-In page 7 you can see the type of bone loss which could be:
1. Vertical : angle in shape.
2. Horizontal.

• Periodontal charting:
Average PI= sum PI / numbers of teeth.
Average GI= sum GI/ numbers of teeth.

Guideline for completing the periodontal worksheet:

• For BOP place a red dot at bleeding site where PD is
documented.
• Mobility value(I-III) is printed on the occlusal surfaces of
mobile teeth.
 • Draw recession on the root with red pencil, every line in the
sheet=1mm.
• x :missing tooth.
• For furcation involvement use a red pencil and follow
Glickman system:
- Class I : V
- Class II: ∆
- Class III: ▲

The End Of The Lecture

Done by:
Abdullah T. Al Halhouli.

Life is not measured by the breaths we take, but by the moments

that take out breath away