CLINICAL DIAGNOSIS

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Learning Objectives:

Overall Appraisal of the Patient

Radiographic aids in the diagnosis of periodontal disease
Normal interdental bone
Radiographic techniques
Bone destruction in periodontal disease
Radiographic appearance of periodontal disease
Digital intraoral radiography
Conclusion
Advanced diagnostic techniques
Conventional routine diagnostic methods
Status of current conventional diagnostic methods
Requirement of Newer diagnostic methods
Advances in radiographic assessment
Advances in microbiologic analysis
Advances in characterizing the host response
Conclusion
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• PROPER DIAGNOSIS - ESSENTIAL TO INTELLIGENT TREATMENT

• First determine whether disease is present

• Disease- type, extent, distribution, severity, underlying pathologic processes &

their cause

• 3 broad categories – Gingival Diseases

Various types of periodontitis
Periodontal manifestations of systemic diseases

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Overall Appraisal of the Patient
• Chief complaint:
1. Visit to dentist should be listed, including their frequency, the date of the
recent visit, the nature of treatment and oral prophylaxis cleaning by the
dentist or hygienist and frequency and date of most recent cleaning
2. The patient oral hygiene regimen should be described, including brushing
technique, frequency, time of the day and dentifrice
3. Any orthodontic treatment including duration and approximate date of
termination
4. If the patient was experiencing pain in the teeth or in the gingiva, the
manner it was provoked, its nature and duration
5. The presence or absence of gingival bleeding, including when it first
occurred; whether it was spontaneous, or on brushing or eating etc
6. A bad taste in mouth and areas of food impaction
7. Whether patient feels loose teeth

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8. Patient general dental habits
9. Patient history of previous periodontal problems
10.Whether patient wearing any RPD and the prosthesis enhances or deters the
existing dentition
11. Whether the patient has implants needs to be noted

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Medical History: The importance of medical history should be clearly
explained because patients often omit information that they cannot relate to
dental problems. The patient is made aware of the following
1. the possible role that some systemic disease, conditions or behavioral
factors may play in the cause of periodontal disease
2. The presence of conditions that require special precautions
3. The possibility that oral infections may have powerful influence on the
occurrence and severity of variety of systemic conditions
The medical history should include:
4. If patient is under physician care, the nature and duration of the problem
and its therapy
5. Details regarding hospitalizations and operations
6. List of medications being taken and whether they were prescribed or
obtained over the counter should be included

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4. All medical problems
5. Any possibility of occupational disease
6. Abnormal bleeding tendencies e.g. nose bleeds, prolonged bleeding after
cuts
7. Allergic to any medication
8. Information is needed regarding history of puberty, pregnancy or
menstruation, menopause from females
9. Family medical history must be taken

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• Casts: Are records of the dentition before it is altered by the treatment and
finally casts provide visual aids when talking to patients in explaining the
treatment

• Clinical Photographs: Digital radiographs are useful especially when

mucogingival surgery are done

• Extraoral examination:

• Examination of lymph nodes: lymph nodes of head and neck should be

routinely examined

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Intraoral examination

Oral Hygiene

Oral Malodor: Also called fetor oris, fetor ex ore and halitosis

Examination of teeth and implants:

1. Wasting Disease of the Teeth- wasting is defined as any gradual loss of
tooth substance, which is characterized by the formation of smooth,
polished surface without regard to possible mechanism of this loss
Erosion: Also called as corrosion, is a sharply defined wedge shaped
depression in the cervical area of the facial tooth surface. Sognnaes named
it as dentoalveolar ablations
Abrasion: refers to the loss of tooth substance that is induced by
mechanical wear other than that of mastication

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Attrition: is occlusal wear that result from functional contacts of the opposing
tooth
Abfraction: result of occlusal loading surface causes flexure, mechanical
microfractures and tooth substance loss in cervical areas

2. Dental Stains: pigmented deposit on the teeth

3. Hypersensitivity: They are located with gentle exploration with the probe or
cold air
4. Proximal Contact Relations:
5. Tooth Mobility: occurs in following two stages:
a) The initial or intrasocket stage occurs when the tooth moves within
confines of the periodontal ligament. The initial movement occurs with
forces of about 100lb and it is on the order of 0.05-0.10mm.
b) The secondary stage occurs gradually and entails the elastic deformation
of the alveolar bone in response to increased horizontal forces. When 500
gms of force is applied to the crown the resulting displacement is 100-200
μm

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Mobility is graded as:
Garde O: normal mobility
Grade I: slightly more than normal
Grade II: moderately more than normal
Grade III: severe mobility faciolingually, mesiodistally or both in combination
with vertical displacement
Mobility beyond physiological range is called abnormal or pathologic
Increased mobility is caused by one or more of the following factors
1. Loss of tooth support
2. Trauma form occlusion
3. Extension of inflammation
4. Periodontal surgery
5. Mobility increased during pregnancy and sometimes associated with
menstrual cycle or use of hormonal contraceptives
6. Pathologic processes of the jaws

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6. Trauma from Occlusion: Refers to tissue injury produced by occusal forces
rather than to the occlusal forces themselves
7. Pathologic migration of the teeth: Alterations in tooth position is carefully
noted, particularly with a view toward identifying abnormal forces, tongue
thrusting or any other habit. Premature tooth contacts in the posterior
region that deflect the mandible anteriorly contribute to the destruction of
the periodontium of the maxillary anterior teeth and to pathologic
migration. The migration in the anterior teeth is sign of localized
aggressive periodontitis
8. Sensitivity to percussion
9. Dentition with the closed jaws: it can detect conditions like irregularly
aligned teeth, extruded teeth, improper proximal contact, and areas of food
impaction, all of which favor plaque accumulation. Excessive overbite and
open bite etc can also be detected
10. Functional occlusal relationships

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• Examination of the Periodontium

Plaque & Calculus

Gingiva

Use of clinical indices in dental practice: of all indices gingival index and
sulcus bleeding index appear to be most useful and are most easily
transferred in dental practice

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• Periodontal Pockets-
1. Signs & symptoms: Although probing is only reliable method of
detecting pockets, clinical signs such as color changes, a rolled edge
separating the gingival margin form the tooth surface, or enlarged,
edematous gingiva might suggest their presence.
2. Detection of pockets: gutta percha or silver points can be used with the
radiograph to find the level of attachment of periodontal pocket
3. Pocket probing: two different depths. A) biologic or histologic depth
B) clinical probing depth.
Biologic depth is distance between gingival margin and the base of the
pocket. Probing depth is distance to which probe penetrates into the
pocket. Probing force is 0.75 N can be well tolerated and accurate
4. Probing technique: The probe should be inserted parallel to the vertical
axis of the tooth and walked circumferentially around each surface of the
tooth to detect deepest penetration. Furcation involvement is detected using
Nabers probe

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5. level of attachment Vs pocket depth: level of attachment is the distance
between CEJ to the base of the pocket, and pocket depth is distance
between gingival margin to the base of the pocket
6. Determining the level of attachment: When the gingival margin is located
on the anatomic crown the level of attachment is determined by
subtracting from the the depth of the pocket the distance form the gingival
margin to CEJ
7. 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. Bleeding can vary from a tenuous red line along with
gingival sulcus to profuse bleeding
8. When to probe: The initial probing of moderate or advanced cases is usually
hampered by presence of inflammation and heavy calculus and it cannot be
accurately done. After the patient has performed adequate plaque control
for some time and the calculus has been removed the major inflammatory
changes disappear and accurate probing can be performed.
9. Probing around implants: A traditional periodontal probe can be used under
light force without damaging periimplant –mucosal seal
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10. Probing force: One of the main problems of reproducibility has been the
variation of probing force. The development of pressure sensitive probes
has helped to overcome this issue. With forces upto 30gms tip of the probe
remains within junctional epithelium and forces above 50 gms are
necessary to reach bone.
11. Probe angulation: Standardization of probe tip and the addition of
registration stents to maintain reproducible probe angulation have been
used to overcome error. New commercially available computer assisted
technology has been used to improve probing accuracy and reproducibility

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• Determination of disease activity: Currently there is no accurate methods
to determine the activity or inactivity of a lesion. Inactive lesions may
show little or no bleeding with probing and minimal amounts if gingival
fluid. Active lesions bleed more readily with probing and have large
amounts of fluids and exudates. The florida probe provides a means of
recording relative CAL changes over the time. A later model of the probe
has a modified sleeve with prominent 0.125mm edge to facilitatea catch of
the CEJ.
• Amount of Attached Gingiva: Distance between the mucogingival
junction and projection on the external surface of the bottom of the
gingival sulcus or the periodontal pocket. The method to measure is use of
schiller’s iodide dye that stains keratinized gingiva, rolls test and clinically
by subtracting the sulcus depth from total width of the gingiva
• Degree of Gingival Recession: The measurement is taken with a
periodontal probe from CEJ to the gingival crest and it is drawn on the
patient chart

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Gingival recession
• Alveolar Bone Loss: probing is helpful
• Palpation
• Suppuration
• Periodontal abscess
Periodontal Abscess & Gingival Abscess

Periodontal Abscess & Periapical Abscess

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• Intraoral radiographic survey: minimal of 14 IOPA and 4 bite wings
films are required for full mouth xrays
• OPG are simple and convenient method of obtaining a survey view of
dental arch and surrounding structures
• Laboratory aids to clinical diagnosis
Nutritional Status

Patients with Special Diets for Medical Reasons

Blood Tests
• Histopathologic examination: Chronic gingivitis, acute gingival lesions
and different types of periodontitis are diagnosed based on the history,
clinical features and radiographs and do not require any microscopic
investigation.

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 Radiographic aids in the diagnosis of
periodontal disease
• The radiograph is a valuable aid in the diagnosis of periodontal disease,
determination of the prognosis, and evaluation of the outcome of
treatment. However radiograph is an adjunct to the clinical examination,
not a substitute for it the radiograph reveals alteration in calcified tissues. It
does not reveals current cellular activity but shows effects of past cellular
experience on the bone & roots.
• Normal Interdental bone: Radiographic evaluation of bone changes in
periodontal diseases is based mainly on appearance of interdental septa ,
because the relatively dense root structure obscures the facial and lingual
bony plates. The interdental septum normally presents a thin radiopaque
border that is adjacent to the PDL and at alveolar crest, termed as Lamina
dura.

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 Full mouth xrays

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• Radiographic techniques: Long cone paralleling technique projects most
realistic image of the level of the alveolar bone. Bisecting of the angle
technique increase the projection & make the bone margin appear closer to
the crown.
• Shifting the cone mesially or distally without changing the horizontal plane
projects the X-ray obliquely & change the shape of the interdental bone on
radiograph. Radiographic width of PDL space &Appearance of lamina
dura. It also distorts the extent of furcation involvement.
• PRICHARD ESTABLISHED FOLLOWING FOUR CRITERIA TO
DETERMINE ADEQUATE ANGULATION OF PERIAPICAL
RADIOGRAPHS
1. The radiograph should show the tips of molar cusps with little or none of
the occlusal surface showing.
2. Enamel caps and pulp chambers should be distinct.
3. Interproximal spaces should be open.
4. Proximal contacts should not overlap unless teeth are out of line
anatomically.

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• Bone destruction in periodontal disease: The earliest signs of periodontal
disease must be detected clinically.
• The radiographic image tends to show less severe bone loss. Difference
between the alveolar crest height and radiographic appearance ranges from
0 – 1.6 mm, mostly accounted for by X-ray angulation.
• Amount of bone loss: Radiographs indirect method for determining the
amount of bone loss in periodontal diseases. Shows amount of remaining
bone rather than amount lost. Amount of bone lost is estimated as
difference between the physiologic bone loss of the patient and the height
of the remaining bone. Distance from CEJ to the alveolar crest: In
adolescents = 2 mm. May be greater in older patients.
•  Distribution: Distribution of bone loss is an important diagnostic sign. It
points to the location of destructive local factors in different areas of in
relation to the mouth different surfaces of same tooth

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• Patterns of bone destruction: Horizontal and vertical bone loss.
Radiographs do not indicate the internal morphology or dep.th of crater
like defects.

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RADIOGRPAHIC APPEARANCE OF PERIODONTAL DISEASE:
Periodontitis:
1. Earliest radiographic changes in periodontitis: Fuzziness plus a break in the
continuity of the lamina dura at the mesial or distal aspect of crest of
interdental septum. These result from extension of gingival inflammation
into the bone causing widening of the vessel channels and a reduction in
calcified tissue at the septal margin.
 2. A wedge shaped radiolucent area is formed at the mesial or distal aspect of
crest of septal bone. The apex of the area is pointed in the direction of the
root. This is produced by resorption of the bone of the lateral aspect of the
interdental septum, with an associated widening of the periodontal space.
 3. The destructive process extends across the crest of the interdental septum
& height is reduced. Fingerlike projections extend from the crest into the
septum. The radiolucent projections into the septum are the result of deeper
extension of inflammation into the bone.
4. Height of the interdental septum if progressively reduced by the extension
of inflammation and the resorption of bone.
5. Opaque line demarcates the portion of root where the labial and lingual
bony plates have been partially or completely destroyed from the
remaining bone supported portion
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Radiographic changes in periodontitis

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• Interdental craters: Interdental craters are seen as irregular areas of
reduced radiography on alveolar bone crests. They are not sharply
demarcated from the rest of the bone, with they bend gradually.
• Furcation involvement:To assist in the radiographic detection of furcation
involvement following criteria are suggested
1. The slightest radiographic change is the furcation area should be
investigated. Clinically, if there is bone loss an adjacent tooth.
2. Diminished radiodensity in the furcation area in which outline of bony
trabeculae are visible, suggests furcation involvement.
3. When there is marked bone loss in relation to a single molar root, it may
be assumed that furcation is also involved.
• Periodontal abscess: The radiographic picture is often not typical because
of many variable such as following:
1. The stage of the lesion – in the early stages the acute periodontal abscess
is extremely painful but presents no radiographic changes
2. The extent of bone destruction & morphologic changes of the bone.
3. The location of the abscess. 

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Periodontal abscess

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• Clinical probing: Done using silver points and gutta percha
• Localized aggressive periodontitis:
1. Initially around max and mandibular incisor and molars
2. As disease progresses, loss of bone might become generalized
• Trauma from occulsion: Radiographically detectable changes in the
lamina dura, morphology of the alveolar crest, width of PDL space, and
density of the surrounding cancellous bone. Traumatic lesions manifest
more clearly in faciolingual aspects, because mesiodistally the tooth has
the added stability provided by the contact areas with adjacent teeth.
Therefore, slight variations in the proximal surfaces may indicate greater
changes in the facial and lingual aspects. The radiographic changes listed
next are not pathognomonic of trauma from occlusion and must be
interepreted in combination with clinical findings, particularly tooth
mobility, presence of wear facets, pocket depth, and analysis of occlusal
contacts and habits.

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Localized aggressive periodontitis

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 Digital intraoral radiography:

• Digital intraoral radiography use either solid state detectors or

photostimulable phosphor plates. Systems with solid state detectors use
either charge coupled device or complementary metal oxide semiconductor
chips as image receptors .

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Digital radiography

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 Advanced diagnostic aids

Conventional routine diagnostic methods:

• Basic methods of periodontal diagnosis have remained the same
1. thorough dental and medical history
2. Recording clinical signs of periodontal inflammation
3. Measurement of probing depth, CAL, and gingival recession
4. Routine radiographs including OPG
5. Routine hematologic tests
6. Histopathologic examination in case of uncommon gingival and mucosal
disorders

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 Status of current conventional diagnostic methods
The positives:
1. Can be performed swiftly with minimum equipments
2. Epidemiologic surveys can be carried out easily and the results are
usually a true representation of the periodontal status of the population.
3. In a clinical setting most, but not all patients can be treated adequately.
The negatives:
4. The measurements are not accurate
5. Full mouth recording is required as the disease is site specific
6. Exact etiology cannot be determined
7. Small changes occurring over a specific time cannot be appreciated
8. There is no reliable markers of current disease activity
9. There is no reliable markers available to identify individual/ sites at risk.
10. It is difficult to determine prognosis
11. They are prone for inter and intra examiner errors
12. A great variability exists in the interpretation of findings
13. A universally accepted classification does not exists
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 Requirements of newer diagnostic methods
1. Accurate measurement of disease
2. Identify individuals / sites at risk of future breakdown
3. Identify the etiologic factor
4. Identify the exact nature of transition from gingivitis to periodontitis
5. Able to aid in determination of prognosis
6. Simple to use
7. Demonstrate high specificity and sensitivity
8. Minimally invasive
9. User friendly with low learning curve
10. Should not be expensive

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Periodontal probing:
 Limitation of conventional probing
• Lack of sensitivity and reproducibility.
• Disparity between measurement depends on: probing technique, probing
force, angle of insertion of probe, size of probe, precision of calibration,
presence of inflammation.
• Readings of clinical pocket depth measured with probe does not coincide
with the histologic pocket depth.
• All these variable contribute to the large standard deviations (0.5-1.3 mm)
in clinical probing results
 Classification of periodontal probes depending on generation
1.First generation probes: (conventional probes) Conventional manual probes
that do not control probing force or pressure and that are not suited for
automatic data collection. example: Williams periodontal probe, CPITN
probe, UNC-15 probe ,Goldman Fox probe

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 2.Second generation probes: (Constant force probes) Introduction of constant
force or pressure sensitive probes allowed for improved standardization of
probing. e.g.: Pressure sensitive probe Constant pressure probe
Limitation: data readout and storage is inaccurate.
3.Third generation probe:(Automated probes) • Computer assisted direct data
capture was an important step in reducing examiner bias and also allowed
for generation of probe precision. (according to NIDCR criteria) e.g.: 
Toronto probe, Florida probe, Interprobe, Foster Miller probe.
Florida probe Tip is 0.4mm , Sleeve- edge provides reference to make
measurements, Coil Spring; provides constant probing force ,Computer for
data storage. FP Handpiece tip as it enters the sulcus. Handpiece tip with
constant force in use (tip at bottom of sulcus) and sleeve properly
positioned at the top of the gingival margin allowing the computer to
measure the difference.

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4. Fourth generation probes: (Three dimensional probes) • Currently under
development, these are aimed at recording sequential probe positions along
a gingival sulcus.
5.Fifth generation probe: (3D + Noninvasive) • Basically these will add an
ultrasound to a fourth generation probes. • If the fourth generation can be
made, it will aim in addition to identify the attachment level without
penetrating it. • e.g.: Ultra sonographic probe.

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Gingival temperature:
• Kung et al (1990) claim that thermal probes are sensitive diagnostic
devices for measuring early inflammatory changes in gingival tissue.
• Subgingival temperature at diseased sites is increased as compared to
normal healthy sites .
• Commercially available system PerioTemp probe enables the calculation of
temperature differential (with sensitivity of 0.10C) between the probed
pocket and subgingival temperature
• Possible explanation for ↑ temperature with increasing probing depth is an
increase in cellular and molecular activity caused by increased periodontal
inflammation.

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 Advances in radiographic assessment
• Digital radiography : Capturing radiographic image using a sensor. The
first direct digital imaging system.
• Advantages
1. Elimination of chemical processing
2. Increased efficiency and speed of viewing
3. Diagnostic information can be enhanced
4. Computerized storage of radiographs
5. Reduced exposure to the radiation
• Subtraction radiography: This is a technique by which images not of
diagnostic value in a radiograph, are eliminated so that changes in the
radiograph can be precisely detected Serial radiographs converted to digital
images superimposed composite image Quantitative changes

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• Recent image subtraction:“diagnostic subtraction radiography” (DSR)
Modification, use of a positioning device during film exposure image
analysis software system applies an algorithm to correct angular alignment
discrepancies.
Computer Assisted Densitometric Image Analysis (CADIA): Video
camera measures the light transmitted through radiograph and the signals
form the camera is converted to gray scale image.
Advantage:
1. Measures quantitative changes in bone density longitudinally.
2. Higher sensitivity, reproducibility and accuracy as compared to DSR.
Other radiographic equipments are: computed tomography (CT ), cone beam
computed tomography(CBCT), Tune aperture computed tomography
(TACT) local CT, optical coherance tomography (OCT)

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 Advances in microbiologic analysis
Bacterial Cultuing •
• Culture techniques are considered as the gold standard when determining
the performance of new microbial diagnostic methods.
• Used to grow and multiply those bacteria which are suited to grow on the
culture medium used which must include all necessary growth
requirements.
 DISADVANTAGES
• Not all bacteria can be readily cultured .
• Also, the use of selective media will restrict the species that are able to grow.
• Strict sampling and transport conditions are essential.
•

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• Moreover, some of the putative pathogens, such as Treponema sp. And
T.forsythus are fastidious and difficult to culture. •
• The sensitivity of culture methods is rather low, since the detection limits
for selective and non-selective media average 103 to 104 bacteria and
hence low numbers of a specific pathogen are undetected.
• The most important drawback is that culture requires sophisticated
equipment and experienced personnel and is relatively time-consuming
and expensive.
Direct microscopy:
Dark field microscopy or phase contrast is used as an alternative to culture
methods on the basis of its ability to assess directly and rapidly the
morphology and motility of bacteria in plaque

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• Immunodiagnostic methods: Employs antibodies that recognize specific
bacterial antigens to destect target microorganisms. • This reaction can be
revealed using variety of procedures, including direct and indirect
immunofluorescent microscopy assays(IFA), flow cytometry, ELISA,
membrane assay and latex agglutination.
• Immunological assays direct and Indirect immunofluorescent
microscopy assays (IFA):
• Direct IFA employs both monoclonal and polyclonal antibodies conjugated
to a fluroscein marker that binds with the bacterial antigen to form a
fluorescent immune complex. Indirect IFA employs secondary fluroscein-
conjugated antibody that reacts with primary antigen antibody complex
• IFA has been used mainly to detect A.a and P.g.
• Zambon et al showed that this technique is comparable to culture in its
ability to identify pathogens in subgingival plaque samples. IFA does not
require viable bacterial cells.
• Drawbacks- separate fluorescent tagged antibodies has to be prepared
against each antigen to be tested.

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• Cytofluorography or flow cytometry:
• Is used for rapid identification of oral bacteria involves labeling bacterial
cells from as patient plaque sample with both species specific antibody and
a second fluroscein conjugated antibody.
• The suspension is introduced in the flow cytometer which separates the
bacterial cells into am almost single cell suspension
• Enzyme-linked immunosorbent assay (ELISA): • ELISA has been used
primarily to detect serum antibodies to periodontopathogens and also in
research to quantify specific pathogens in subgingival samples using
specific monoclonal antibodies. The assay can only detect species for
which a suitable antibody is available
•  Latex agglutination test • Latex beads are coated with the species specific
antibody, and when these beads come in contact with microbial cell surface
antigens or antigen extracts, cross-linking occurs and agglutination or
clumping is seen within 2-5mins.

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• Enzymatic Methods: It is an enzymatic assay used for the identification
of the trypsin-like protease which is produced mainly by P.g and to a much
lesser extent by T.forsythus and T. denticola and Capnocytophaga species.
• This protease hydrolyses benzyol-DL-arginine-2- naphthylamide
(BANA) substrates in a colorimetric assay. • The activity of the enzyme is
measured with the hydrolysis of the colorless substrate BANA resulting in
release of chromophore beta naphthylamide resulting in orange red colour.
• Diagnostic assays based on molecular biology techniques:
Nucleic acid probe: A probe is a known nucleic acid either DNA or RNA
from a specific microorganism artificially synthesized and labeled for its
detection when placed with plaque samples. DNA probe is a fragment of
nucleic acid, labeled with an enzyme or a radioisotope, that can seek out
and bind itself to other complementary sequences of DNA, thus forming
the double helix structure found in nature. commercially available
diagnostic methods (DMDx and Omnigene)

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Checkerboard DNA-DNA hybridization:
• Socransky et al developed this technique by for the detection and levels of
40 bacterial species often found in the oral cavity. The assay uses whole
genomic, digoxigenin –labeled DNA probes and facilitates rapid
processing of large numbers of plaque samples with multiple hybridization
for upto 40 oral species.
Polymerase chain reaction:PCR involves amplification of an exceedingly
small region of DNA flanked by a selected primer specific for target
species. • The presence of the specific amplification product indicates the
presence of the target microorganisms. Among the different nucleic acid
assays, PCR demonstrates the best detection limits, as few as 5-10 cells
and shows no cross-reactivity under optimized amplification conditions.
• Modifications • Multiple PCR • Nested PCR • Quantitative PCR

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 Advances in characterizing the host response
Sources of the samples:
• GCF, saliva and blood serum and blood cells and urine. However analysis
of urine shows little promise except for its use in the differential diagnosis
of tooth loss related to hypophosphatasia in young children.
• GCF has 60 components or more and divided into host derived enzymes,
tissue breakdown products and inflammatory mediators
Inflammatory mediators and products:
•  Cytokines are potent local mediators of inflammation present in GCF.
• Cytokines investigated as potential markers include TNF-α, IL- 1 α, IL-1β,
IL-6 and IL-8. IL-1, IL-6 and TNF-α are produced by macrophages and
other cells at inflamed sites.
• Good candidates for markers of disease progression.
• Prostaglandin E2 is formed as a result of the metabolism of arachidonic
acid through cyclooxygenase pathway. It is a potent mediator of
inflammation and bone resorption. In cases of active periodontal
destruction, the level of GCF PGE2 is dramatically increased.
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• Host derived enzymes: Various enzymes are released from host cells
during initiation and progression of periodontal disease. Some of these
enzymes are released from dead and dying cells of the periodontium
whereas some come from PMN and others are produced by inflammatory,
epithelial and C.T cells at affected sites.
Aspartate aminotransferase (AST):
• Cytoplasmic enzyme
• Extracellular release is associated with cell damage and cell death.
• Marked elevation in AST levels in GCF samples from sites with severe
gingival inflammation and sites with a recent history of progressive
attachment loss
• Periogard is a rapid chair side test kit for AST
• Pocket watch: An in vitro diagnostic test kit to analyze AST levels in GCF
and is used as an objective biochemical test for diagnosing and monitoring
the disease activity to determine when to treat and also to evaluate the
treatment effectiveness.

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Elastase
• produced by neutrophils in inactive form bound to inhibitor.
• Active elastase is usually seen adjacent to JE where neutrophils are
mirating.
• Elastase is able to degrade proteoglycans and can also activate latent
collagenase.

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Prognostik (DENTSPLY): • Detects the presence of the serine proteinase,
elastase, in GCF samples.
Alkaline phosphatase
• Is found in many cells of the periodontium including osteoblasts, fibroblast
and neutrophils.
Periocheck detects neutral proteinases
 Β-glucuronidase and Aryl sulphatase:
• Both these enzymes are lysosomal and are found in the primary granules
of neutrophils.
• Lamster I B (1988) shown that concentration of this enzyme may have
predictive value in identifying patients at higher risk for losing attachment.

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Collagenase:
• Family of matrix metalloproteinases (MMPs)
• synthesized by macrophages, neutrophils, fibroblasts and keratinocytes and
are secreted as latent enzymes.
• The 2 principal types of specific collagenase are MMP-8 which is found in
inflammatory cells such as neutrophils and MMP-1 found in fibroblasts
and other cells.
• Collagenase (MMP-8, MMP-1) activity if found in gingival tissue, saliva
and GCF and can be assayed biochemically with collagen substrates or by
using monoclonal antibodies with ELISA.

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TISSUE BREAKDOWN PRODUCTS
• The tissues of the periodontium exist in a delicate balance between health
and disease as well as between repair and regeneration.
• Both catabolic and anabolic products from the ECM may be present in the
GCF. These are potentially important marker of disease and tissue turnover
 

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Conclusion: Although there are many potential markers for
periodontal disease activity and progression, numerous factors
still hamper their use as diagnostic tests of proven gold
standard disease progression, thus correlation with potential
markers with proven clinical attachment loss may be potential
confounder in any proposed test.

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Long Questions:
1. Clinical Features, radiographic appearance, histopathological features of
trauma from occlusion
Short Notes:
2. Probing
3. Wasting diseases of the teeth
4. Mobility
5. Trauma from Occlusion
6. Pathologic Migration
7. Attached Gingiva
8. Periodontal Abscess
9. Gingival Abscess

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Long Questions:
1. Write about advances in radiographic assessment / microbiologic analysis.

Short Notes:
2. BANA Test
3. DNA Probes

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 THANK YOU

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