Examination, Diagnosis
and Prognosis
Dr Nael Al Masri
periodontist
Patient –doctor relationship
Chief complaint
Past and present medical and dental
problem
Examination
Diagnosis and prognosis
Treatment plan
Medical History
Medical problems (cardiovascular, endocrine,
hematologic etc.)
Abnormal bleeding
Allergy
Puberty and pregnancy
Previous surgery or hospitalization
Medications
Family medical history
Dental History
Oral hygiene regimes
Previous dental and periodontal procedures
Previous Periodontal problems
Restorative and orthodontic treatment
Dental and medical history help dentist to
:determine risk factors
Patient compliance
Systemic disease like diabetes
Medication
Hormonal changes
Smoking
Genetics
Stress
Most common chief complaint
Bleeding
Heavy calculus
Halitosis
Loose teeth
Food impaction and pain
Pain
– Esthetic
color , asymmetry
Receding gum
Gummy smile
Periodontal examination
Identifying status of periodontal tissue
)Health, Gingivitis ,Periodontitis(
Detect clinical signs of inflammation if present
Detect the cause of inflammation ( trauma or disease)
Establish diagnosis and prognosis
Treatment plan
Evaluation of efficacy of treatment
Periodontal examination
Plaque and calculus
Presence of local contributing factors
) anatomic and iatrogenic(
)Signs of gingival inflammation
Bleeding on probing
Probing pocket depth (PPD)
Clinical Attachment level (CAL)
Alveolar bone loss (radiograph)
Tooth mobility
Furcation involvement
Amount of attached gingiva and muco-gingival level
Detection of plaque
Direct vision
Thin plaque usually not visible ,only if it stained
Thick plaque visible :teeth look dirty
Use of explorer
Plaque adhere to explorer tip ( plaque index)
Use of disclosing agents
Iodine containing solutions
Erythrosine
Plaque Disclosing Agents
Indices Used For Oral Hygiene Assessment
PLAQUE INDEX
Silness and Loe in 1964
Assesses only thickness of plaque at the
cervical margin of the tooth closest to
the gums Rating Scores
Excellent 0
Good 0.1-0.9
Fair 1.0-1.9
Poor 2.0-3.0
Examination of plaque
Plaque Index (Pl)
introduced by Silness and Loe in 1964
This index measures the thickness of plaque on the gingival one third to
. evaluate oral hygiene
Examination of Gingiva
Visual signs of inflammation
Color, size & position, contour, consistency , surface
texture, presence of pus
Bleeding on Probing
Gingival index (GI)
Uses of Periodontal Probes in the
Comprehensive periodontal Assessment
Bleeding on probing
Probing depth
Clinical attachment level
Recession of the gingival margin
Amount of attached gingiva
Furcation involvement
Bleeding on probing
Bleeding on gentle probing is a clinical sign of gingival inflammation
)First sign of inflammation (
Is predictor of periodontal stability and give information about
disease activity
Bleeding + = active disease , inflammation
Bleeding - = stable condition
Bleeding and pain during probing due to ulceration of soft
tissue wall of periodontal pocket
:Technique
This procedure done by walking of periodontal probe in the
sulcus /pocket and waiting for 30 seconds
Bleeding after gentle probing can occur immediately or after 30
seconds depend on severity of inflammation
Excessive force during probing can cause bleeding
)probing pressure should not exceed 25 g(
Clinical Significance of bleeding on probing
Correlation between bleeding on probing and severity of gingival
disease and presence of bacterial plaque
Gingival index (GI) Silness and Loe
Determine the severity of gingival inflammation
(Plaque Induced Gingivitis)
Periodontitis
In clinical practice, periodontitis is assessed
:by a full mouth examination that includes
Calculation of CAL
Recording of true periodontal pocket
Recording of recession
Bone resorption
Mobility
Furcation involvement
Probing depth (PD)
It’s the distance from free gingival margin to the base of
sulcus or pocket
Clinical attachment level(CAL)
Distance from the CEJ to the
bottom of the sulcus or pocket
Clinically attachment loss
manifested as:
Deep periodontal pocket
Recession or both
Furcation involvement
POCKET PROBING
Two different pocket depths
Biologic or histologic depth Clinical or probing depth
Distance between gingiva Distance to which a probe
margin and base of the pocket penetrates into the pocket
Factors affecting probing
Probing force
Standardized force used for penetration of a probe is 25 grams (0.75 N).
Probing direction
Tissue resistance
Size and shape of probe
Clinical significance of PD
:Probing depth > 3mm mains Pathology
Deep pocket (gingival or periodontal )
Oral hygiene difficult to perform by patient
: Deep pocket associated with
Disease progression
Bleeding on probing
Higher level of anaerobic pathogenic bacteria
Reduction of probing depth indicate improvement after
periodontal therapy
Probing Technique
I – Probe must be parallel to long axis of tooth
in six point buccally and lingually
Gently “walk” the probe
Readings
Six readings
Distal (DB & DL)
Buccal (B) or Lingual (L)
Mesial (MB & ML)
Deepest reading within the designated areas
PROBING TECHNIQUES
II- Interproximal probing to detect deep pockets in posterior teeth (presence of Interproximal bone
resorption )
Probe should be inserted with
angle of 10- 15 degree
Slightly tilted
Apical to the contact point
Not enough Correct Too much
angulation
angulation angulation
Gingival enlargement
( Gingival margin is significantly coronal to the CEJ)
Probing depth more than 3mm(normal sulcus is 3mm)
Gingival enlargement = distance from gingival margin to CEJ
Edematous fibrous mixed
Loss of Clinical Attachment
Loss of attachment is critical factor in distinguishing between gingivitis and
periodontitis
Gingival Inflammation without attachment loss called gingivitis
while with attachment loss called periodontitis
Severity of periodontitis depend on amount of (CAL)
Significance of
CAL
Probing depth influenced by gingival level while clinical attachment
level measured at fixed point
Gingival levels changes over time(swelling ,enlargement or recession
For that CAL is more accurate in assisting of tooth supporting tissues
than PD ( SEVERITY OF PERIODONTITIS)
CEJ
CAL
gingival level
Different pocket depths with the same amount of attachment loss
Calculating Clinical Attachment Level
Two measurements are used to calculate the clinical attachment level:
1-The probing depth
2- Gingival margin (distance from CEJ to gingival margin)
The gingival margin may be:
1- At the CEJ
2- Significantly coronal to the CEJ (gingival enlargement)
3- Apical to the CEJ (gingival recession)
I- Gingival margin at CEJ
CAL = PD
Probing depth by probe
II- CAL in presence of recession
:)Gingival margin is apical to the CEJ(
CAL = PD(4mm) + Gingival Recession (2mm) = 6mm
Gingival Recession = 2
Probing depth = 4
III- CAL in presence of gingival enlargement
Gingival enlargement maybe with or without loss of attachment
CAL= 9 – 3= 6mm
CAL = PD( 9mm) – Gingival enlargement( 3mm ) = 6mm
Some clinicians prefer measure CAL after
removing supra and subgingival calculus
Better access and vision
Shrinkage of gingiva after therapy
Calculus makes probing depth inaccurate
Amount of attached gingiva
Mucogingival junction
Significance of attached gingiva
The more width of attached gingiva , the gingiva is more resistant to
plaque and inflammation
More stable periodontal tissue , less inflammation, less recession
Measurement of width of attached gingiva
ALVEOLAR BONE SUPPORT IN HEALTH AND
DISEASE
Health Gingivitis
No loss of alveolar bone
In health:
The crest of the alveolar bone is located 1 to 2 mm apical to (below) the
cementoenamel junctions (CEJs) of the teeth
BONE LOSS IN PERIODONTITIS
Periodontitis with deep periodontal pockets
Periodontitis with recession
Assissing alveolar bone loss
Radiograph
Radiograph give us information about disease history
BUT not disease activity
Good indicator for periodontal regeneration after
periodontal therapy
Transgingival probing (bone
sounding)
:Disadvantages of radiograph
Radiograph indicates areas of bone loss where pocket may be
suspected, they do not show presence or depth of
periodontal pocket
Radiograph show no difference before or after pocket
elimination unless bone has been modified
Suppuration
Pus is composed mainly of dead white blood cells
and can occur in any infection
Visible pus after finger pressure on the periodontal
pocket
TOOTH MOBILITY
Is the loosening of a tooth in its socket
Mobility may result from loss of bone support around the tooth
Horizontal tooth mobility Vertical tooth mobility
Tooth mobility
Pathologic tooth mobility:
Grade 0: normal mobility (not visible)
Grade I Slight mobility: up to 1mm in horizontal
direction
Grade II Moderate mobility : greater than 1mm but
less than 2mm in horizontal , no vertical mobility
Grade III Severe mobility : severe horizontal + vertical
Fremitus :is palpable or visible movement of teeth in
function
Furcation involvement
In health, the furcation area cannot be probed because it is filled with
alveolar bone and periodontal ligament fibers
loss of attachment and bone in furcation area
Mandibular molars usually bifurcated
Maxillary molars usually trifurcated
Class I, II, III
(Nabers probe)
FURCATION INVOLVEMENT can be detected clinically by Naper's
probe or by radiograph
health Furcation involvement
CLASS1- probe penetrate no more than 1 mm(beginning )
ClASS 2- probe penetrate more than 1 mm but not pass
completely through the furcation (cul de sac )
CLASS 3- through-and-through
ClASS 4- clinically visible class 3 due to recession
