Periodontal ExaminationPeriodontal Examination

Gingival Examination.Gingival Examination. Probing Depth (PD).Probing Depth (PD). Clinical Attachment Level (CAL).Clinical Attachment Level (CAL). Bleeding upon Probing (BOP).Bleeding upon Probing (BOP). Mobility Assessment/fremitus.Mobility Assessment/fremitus. Furcation AssessmentFurcation Assessment Occlusal AssessmentOcclusal Assessment Mucogingival AssessmentMucogingival Assessment RadiographsRadiographs Tooth vitalityTooth vitality Etiologic factorsEtiologic factors

Objectives:Objectives:

Identify the pathological changes of the Identify the pathological changes of the periodontal tissues.periodontal tissues.

Accurately collect/chart following clinical data:Accurately collect/chart following clinical data: Probing depth.Probing depth. Bleeding on probing points/SuppurationBleeding on probing points/Suppuration Furcation involvements.Furcation involvements. Tooth mobility/ fremitus.Tooth mobility/ fremitus. Gingival recession.Gingival recession. Mucogingival defects.Mucogingival defects. Plaque score.Plaque score. Analyze the clinical data and develop an overall Analyze the clinical data and develop an overall

diagnosis for the patient.diagnosis for the patient.

Gingival Examination

Evaluate tissue changes in terms of:

Color. Consistency. Contour.

Gingival Indices Used for evaluation and quantitation of

gingivitis.

.

Gingival Index (GI)Gingival Index (GI) ((Loe & Loe & SilnessSilness):):

Scores gingival inflammation from 0-3 on the facial, Scores gingival inflammation from 0-3 on the facial, lingual and mesial surfaces of all teeth.lingual and mesial surfaces of all teeth.

Grade 0Grade 0 – normal gingiva, no inflammation, no – normal gingiva, no inflammation, no discoloration, no bleedingdiscoloration, no bleeding

Grade 1Grade 1 – mild inflammation, slight color change, – mild inflammation, slight color change, mild alteration of gingival surface, no bleedingmild alteration of gingival surface, no bleeding

Grade 2Grade 2 – moderate inflammation, erythema, – moderate inflammation, erythema, swelling, bleeding on probing or when pressure swelling, bleeding on probing or when pressure appliedapplied

Grade 3Grade 3 – severe inflammation, severe erythema – severe inflammation, severe erythema and swelling, tendency toward spontaneous and swelling, tendency toward spontaneous hemorrhage, some ulcerationhemorrhage, some ulceration

Periodontal ExaminationPeriodontal Examination

Periodontal PocketPeriodontal Pocket Gingival pocket, suprabony pocket, Gingival pocket, suprabony pocket,

intrabony pocketintrabony pocket Simple pocketSimple pocket Compound pocketCompound pocket Complex pocketComplex pocket Attachment lossAttachment loss Configuration of the pocketConfiguration of the pocket Bone sounding/configuration of the bony Bone sounding/configuration of the bony

defectsdefects

Probing Depth:Probing Depth:

- The distance from the soft tissue (gingiva - The distance from the soft tissue (gingiva or alveolar mucosa) margin to the tip of or alveolar mucosa) margin to the tip of the periodontal probe during usual the periodontal probe during usual periodontal diagnostic probing.periodontal diagnostic probing.

The health of attachment can affect the The health of attachment can affect the measurement.measurement.

- over probing in inflamed tissue → probed - over probing in inflamed tissue → probed too far and punctured everything, too far and punctured everything, probes right down to boneprobes right down to bone

- underprobing in healthy tissue → tissue - underprobing in healthy tissue → tissue too tight to get probe in.too tight to get probe in.

Information from probingInformation from probing

Bleeding on probingBleeding on probing Root depositsRoot deposits Pocket depth/probing depthPocket depth/probing depth Furcation involvementFurcation involvement Anatomy of the rootAnatomy of the root

Factors Affecting Probing Factors Affecting Probing DepthDepth

Inflammation. Inflammation. Presence of subgingival calculus.Presence of subgingival calculus. Angulation of probe.Angulation of probe. Probing force.Probing force. Probe tip diameter – 0.5 mm is standardProbe tip diameter – 0.5 mm is standard Patient comfort and tolerance.Patient comfort and tolerance. → → don’t use metal probe w/ implantsdon’t use metal probe w/ implants

Clinical Attachment levelClinical Attachment level

Definition:Definition: The distance from CEJ to the tip of a The distance from CEJ to the tip of a

periodontal probe during usual periodontal probe during usual periodontal diagnostic probing. The periodontal diagnostic probing. The health of Attachment apparatus can health of Attachment apparatus can affect the measurement.affect the measurement.

Distance from CEJ to gingival margin Distance from CEJ to gingival margin + probing depth+ probing depth

Bleeding on Probing Bleeding on Probing (BOP)(BOP)

It is usually a reliable predictor of It is usually a reliable predictor of periodontal disease progression periodontal disease progression but but not not in in smokers smokers where the where the vasoconstrictors mask bleeding.vasoconstrictors mask bleeding.

Bleeding on Probing Bleeding on Probing (BOP)(BOP) – It is It is

expressed expressed as a % of as a % of number of number of bleeding bleeding sites sites divided by divided by the total the total number of number of sites..sites..

Tooth MobilityTooth Mobility Causes of mobilityCauses of mobility:: Trauma from occlusion.Trauma from occlusion. Inflammation.Inflammation. Loss of support.Loss of support. Non-periodontal causes.Non-periodontal causes.

Mobility testMobility test:: Can be performed by the end of two blunt Can be performed by the end of two blunt

instruments or electronically by the Periotestinstruments or electronically by the Periotest Scale for Mobility AssessmentScale for Mobility Assessment Grade IGrade I Slight Slight Up to 1mmUp to 1mm Grade IIGrade II Moderate Moderate Between 1-2mmBetween 1-2mm Grade IIIGrade III Advanced Advanced Over 2 mm and Over 2 mm and

Tooth depressible Tooth depressible

FremitusFremitus

Palpable or visible movement of a tooth Palpable or visible movement of a tooth when subjected to occlusal forces.when subjected to occlusal forces.

Associated with increase bone and Associated with increase bone and attachment loss.attachment loss.

place index finger on labial Surface of place index finger on labial Surface of maxillary teeth.maxillary teeth.

Ask the patient to grind in lateral and Ask the patient to grind in lateral and protrusive movevement.protrusive movevement.

Any movement seen or felt is termed Any movement seen or felt is termed fremitus.fremitus.

Furcation AssessmentFurcation Assessment

Etiology of furcation invasionEtiology of furcation invasion:: Extension of inflammatory periodontal Extension of inflammatory periodontal

disease.disease. Pulpal disease.Pulpal disease. Defective plaque retentive restorations.Defective plaque retentive restorations. Anatomical variations: Enamel pearl Anatomical variations: Enamel pearl

Cervical enamel projectionsCervical enamel projections Existence of accessory pulpal canals.Existence of accessory pulpal canals.Furcation AssessmentFurcation Assessment Class lClass l Class llClass ll Class lllClass lll Class lVClass lV

Mucogingival AssessmentMucogingival Assessment

Includes:Includes: Marginal tissue recession.Marginal tissue recession. Inadequate attached Inadequate attached

gingiva.gingiva. High frenum.High frenum.

Gingival RecessionGingival Recession Miller’s Classification of Marginal Tissue RecessionMiller’s Classification of Marginal Tissue Recession Class I:Class I: Marginal tissue Marginal tissue does notdoes not extend to MGJ. extend to MGJ. No loss of bone or soft tissue of interdental area. No loss of bone or soft tissue of interdental area. Class II:Class II: Marginal tissue recession extends to or beyond the MGJ.Marginal tissue recession extends to or beyond the MGJ. No loss of bone or soft tissue of interdental areaNo loss of bone or soft tissue of interdental area Class III:Class III: Marginal tissue recession extends to or beyond the MGJ.Marginal tissue recession extends to or beyond the MGJ. There is of bone and/or soft tissue loss interdentally. ORThere is of bone and/or soft tissue loss interdentally. OR There is malpositioning of the tooth.There is malpositioning of the tooth. Class IV:Class IV: Marginal tissue extends to or beyond the MGJ.Marginal tissue extends to or beyond the MGJ. Severe bone and soft tissue loss interdentally and or severe Severe bone and soft tissue loss interdentally and or severe

tooth mal position.tooth mal position.

Miller’s Classification of Miller’s Classification of Marginal Tissue RecessionMarginal Tissue Recession

Occlusal TraumaOcclusal Trauma

An injury to the periodontal ligament An injury to the periodontal ligament and alveolar bone as a result of and alveolar bone as a result of excessive forces.excessive forces.

There are 2 types of occlusal trauma:There are 2 types of occlusal trauma:

Primary Primary

Secondary Secondary → due to bone loss→ due to bone loss

Plaque Control RecordPlaque Control RecordO’Leary et al. 1972O’Leary et al. 1972

use disclosing tablets use disclosing tablets Plaque Score (%)= Plaque Score (%)= Number of surfaces with plaque X 100Number of surfaces with plaque X 100 Number of teeth X 4Number of teeth X 4

Factors that hinder patient’s plaque control:Factors that hinder patient’s plaque control: Calculus.Calculus. Poor restoration margins.Poor restoration margins. Over-contoured restorations.Over-contoured restorations. Removable partial appliances.Removable partial appliances.

Clinical indicators of occulsal Clinical indicators of occulsal trauma:trauma:

Mobility (progressive)Mobility (progressive) FremitusFremitus Premature occlusal contacts.Premature occlusal contacts. Wear facets in presence of other clinical Wear facets in presence of other clinical

indicators.indicators. Tooth migration.Tooth migration. Fractured toothFractured tooth Thermal sensitivity.Thermal sensitivity.Radiographic indicators of occlusal trauma:Radiographic indicators of occlusal trauma: Widended PDL.Widended PDL. Bone loss.Bone loss. Root resorption.Root resorption.

Radiographic Assessment

For radiographic assessment the information needed is

Bone Loss Horizontal Vertical

Endodontic involvement Root deposits Root anatomy Root length

Periodontal PrognosisPeriodontal Prognosis  

Prognosis is a prediction of Prognosis is a prediction of

the probable course and the probable course and outcome of a disease. It is outcome of a disease. It is determined following initial determined following initial examination, and following examination, and following active therapy phase.active therapy phase.

Importance: Importance:

For ClinicianFor Clinician:: To determine which treatment To determine which treatment

modalities will be most effective.modalities will be most effective. To develop restorative To develop restorative

recommendation and treatment recommendation and treatment plans.plans.

For Patient: For Patient: To determine whether treatment To determine whether treatment

seems worthwhile.seems worthwhile.

Factors to consider when Factors to consider when assigning a prognosisassigning a prognosis

  Overall PrognosisOverall Prognosis   Age Age – younger is worse → fast process– younger is worse → fast process Medical StatusMedical Status – disease, risk etc – disease, risk etc Rate of progressionRate of progression – chronic vs aggressive – chronic vs aggressive Patient cooperationPatient cooperation Knowledge and ability of dentistKnowledge and ability of dentist.. Etiologic factorsEtiologic factors – root grooves – root grooves Oral habits Oral habits – bruxism, damaging contacts– bruxism, damaging contacts

Should treatment be undertaken?Should treatment be undertaken? Is it likely to succeed?Is it likely to succeed? When prosthetics are needed are the When prosthetics are needed are the

teeth in question to support the teeth in question to support the additional burden? additional burden? 

  

Individual Tooth Individual Tooth prognosis:prognosis:  

Root formRoot form

- Short rooted teeth have worse - Short rooted teeth have worse crown/root → worse prognosis, crown/root → worse prognosis,

- Fused roots worse than - Fused roots worse than bifurcatedbifurcated

CariesCaries

- Local risk factor for periodontal - Local risk factor for periodontal diseasedisease

Tooth positionTooth position - Out of alignment has less - Out of alignment has less

buccal plate → ↑ recessionbuccal plate → ↑ recession - mesial tilt → harder to clean and - mesial tilt → harder to clean and

treattreat Strategic valueStrategic value - Consideration for abutments- Consideration for abutments Therapist knowledge and skillTherapist knowledge and skill..

Periodontal Treatment Periodontal Treatment PlanningPlanning

INITIAL THERAPY TREATMENT PLANINITIAL THERAPY TREATMENT PLAN(Phase I therapy)(Phase I therapy)

: : Plaque Control InstructionPlaque Control Instruction..Supragingival Removal of CalculusSupragingival Removal of CalculusRecontouring Defective Restorations Recontouring Defective Restorations

and Crownsand Crowns..Obturation of Carious Lesions &Obturation of Carious Lesions & removal of plaque retentive areasremoval of plaque retentive areas

RE-EVALUATION PHASERE-EVALUATION PHASE

Objectives: Objectives: 1. To assess tissue response to therapy1. To assess tissue response to therapy

a. Gingival Condition.a. Gingival Condition.

b. Pocket Depths.b. Pocket Depths. 2. To assess patient’s compliance with OHI2. To assess patient’s compliance with OHI

a. Plaque and Bleeding Indexa. Plaque and Bleeding Index

b. Review OHIb. Review OHI 3. To Assess need/advisability for further 3. To Assess need/advisability for further

periodontal therapies.periodontal therapies.

  

SURGICAL PHASESURGICAL PHASEIndications for surgical Phase:Indications for surgical Phase:. . •Pocket depth.Pocket depth.•Osseous and furcation defects. Osseous and furcation defects. •Gingival enlargement.Gingival enlargement.•Inadequate biologic width.Inadequate biologic width.• Mucco-gingival defects.Mucco-gingival defects.• pre-prosthetic plastic Surgerypre-prosthetic plastic Surgery

- Gingival Grafts- Gingival Grafts- Ridge Augmentation- Ridge Augmentation- Crown Lengthening- Crown Lengthening

MAINTENANCE PHASEMAINTENANCE PHASE

ObjectivesObjectives To prevent the progression and To prevent the progression and

recurrence of periodontal recurrence of periodontal disease.disease.

To prevent the loss of dental To prevent the loss of dental implants after clinical stability implants after clinical stability has been achieved.has been achieved.

  

To reduce tooth loss by To reduce tooth loss by monitoring the dentition and any monitoring the dentition and any prosthetic replacement of the prosthetic replacement of the natural teeth.natural teeth.

To diagnose and manage, other To diagnose and manage, other diseases or conditions found diseases or conditions found within the oral cavity.within the oral cavity.

  

Compliance and its Role in Compliance and its Role in Periodontal TherapyPeriodontal Therapy

Compliance) has been defined as Compliance) has been defined as “ the extent to which a person’s “ the extent to which a person’s behavior coincides with medical behavior coincides with medical or health advice”.or health advice”.

  

Compliance in Periodontics: Why Compliance in Periodontics: Why patients fail to comply?patients fail to comply?

- Financial reasons- Financial reasons - Lack of information- Lack of information - Time conflicts with job- Time conflicts with job - Length of periodontal - Length of periodontal

treatmenttreatment - Chronic nature of the disease- Chronic nature of the disease

Chapter 1,2 assessmentChapter 1,2 assessment What is the information I get from What is the information I get from

reviewing the medical/dental history?reviewing the medical/dental history? What do I look for in gingival What do I look for in gingival

examination?examination? What is clinical attachment lossWhat is clinical attachment loss What is the index used for assessing What is the index used for assessing

gingival bleeding and the gingival bleeding and the significance of gingival bleeding?significance of gingival bleeding?

What is Glickmans classification for What is Glickmans classification for furcation assessment?furcation assessment?

What does Mucogingival Assessment What does Mucogingival Assessment include?include?

What is Miller’s classification for gingival What is Miller’s classification for gingival recession?recession?

What is Fremitus? How is mobility What is Fremitus? How is mobility assessed?(assessed?(Scale for Mobility Scale for Mobility Assessment)Assessment)

Which type of radiograph is used for Which type of radiograph is used for periodontal treatment and why?periodontal treatment and why?

How can you assess tooth vitality?How can you assess tooth vitality? What are the What are the Clinical indicators of Clinical indicators of

occulsal trauma?occulsal trauma?

What are the What are the radiographic indicators of radiographic indicators of occlusal traumaocclusal trauma

what is the information needed in what is the information needed in radiographic assessment?radiographic assessment?

What kind of information can I get What kind of information can I get from probing?from probing?

What is the biologic width and its What is the biologic width and its significance?significance?

What are the gingival biotypes ?What are the gingival biotypes ?