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Periodontal Examination

 Gingival Examination.
 Probing Depth (PD).
 Clinical Attachment Level (CAL).
 Bleeding upon Probing (BOP).
 Mobility Assessment/fremitus.
 Furcation Assessment
 Occlusal Assessment
 Mucogingival Assessment
 Radiographs
 Tooth vitality
 Etiologic factors
Objectives:

 Identify the pathological changes of the periodontal


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

Scores gingival inflammation from 0-3 on the facial,


lingual and mesial surfaces of all teeth.

 Grade 0 – normal gingiva, no inflammation, no


discoloration, no bleeding
 Grade 1 – mild inflammation, slight color change, mild
alteration of gingival surface, no bleeding
 Grade 2 – moderate inflammation, erythema, swelling,
bleeding on probing or when pressure applied
 Grade 3 – severe inflammation, severe erythema and
swelling, tendency toward spontaneous hemorrhage,
some ulceration
Periodontal Examination

 Periodontal Pocket
 Gingival pocket, suprabony pocket, intrabony
pocket
 Simple pocket
 Compound pocket
 Complex pocket
 Attachment loss
 Configuration of the pocket
 Bone sounding/configuration of the bony
defects
 Probing Depth:
 - The distance from the soft tissue (gingiva or
alveolar mucosa) margin to the tip of the
periodontal probe during usual periodontal
diagnostic probing.

 The health of attachment can affect the


measurement.

 - over probing in inflamed tissue → probed too


far and punctured everything, probes right
down to bone

 - underprobing in healthy tissue → tissue too


tight to get probe in.
Information from probing

 Bleeding on probing
 Root deposits

 Pocket depth/probing depth

 Furcation involvement

 Anatomy of the root


Factors Affecting Probing
Depth
 Inflammation.
 Presence of subgingival calculus.

 Angulation of probe.

 Probing force.

 Probe tip diameter – 0.5 mm is standard

 Patient comfort and tolerance.

 → don’t use metal probe w/ implants


Clinical Attachment level

Definition:
 The distance from CEJ to the tip of a
periodontal probe during usual
periodontal diagnostic probing. The
health of Attachment apparatus can
affect the measurement.
 Distance from CEJ to gingival margin +
probing depth
Bleeding on Probing
(BOP)

 Itis usually a reliable predictor of


periodontal disease progression but not in
smokers where the vasoconstrictors mask
bleeding.
Bleeding on Probing
(BOP) – It is
expressed as
a % of
number of
bleeding sites
divided by
the total
number of
sites..
 Tooth Mobility
 Causes of mobility:

 Trauma from occlusion.


 Inflammation.
 Loss of support.
 Non-periodontal causes.
 Mobility test:
 Can be performed by the end of two blunt instruments
or electronically by the Periotest

 Scale for Mobility Assessment
 Grade I Slight Up to 1mm
 Grade II Moderate Between 1-2mm
 Grade III Advanced Over 2 mm and Tooth
depressible
Fremitus

Palpable or visible movement of a tooth when


subjected to occlusal forces.
 Associated with increase bone and attachment loss.
 place index finger on labial Surface of maxillary
teeth.
 Ask the patient to grind in lateral and protrusive
movevement.
 Any movement seen or felt is termed fremitus.
Furcation Assessment
Etiology of furcation invasion:
 Extension of inflammatory periodontal disease.
 Pulpal disease.
 Defective plaque retentive restorations.
 Anatomical variations: Enamel pearl Cervical
enamel projections
 Existence of accessory pulpal canals.

Furcation Assessment
 Class l
 Class ll
 Class lll
 Class lV
Mucogingival Assessment

 Includes:

 Marginal tissue recession.


 Inadequate attached gingiva.
 High frenum.
Gingival Recession
 Miller’s Classification of Marginal Tissue Recession
 Class I:
 Marginal tissue does not extend to MGJ.
 No loss of bone or soft tissue of interdental area.
 Class II:
 Marginal tissue recession extends to or beyond the MGJ.
 No loss of bone or soft tissue of interdental area
 Class III:
 Marginal tissue recession extends to or beyond the MGJ.
 There is of bone and/or soft tissue loss interdentally. OR
 There is malpositioning of the tooth.
 Class IV:
 Marginal tissue extends to or beyond the MGJ.
 Severe bone and soft tissue loss interdentally and or severe tooth mal
position.
Miller’s Classification of
Marginal Tissue Recession
Occlusal Trauma

 An injury to the periodontal ligament and


alveolar bone as a result of excessive
forces.
 There are 2 types of occlusal trauma:

Primary
Secondary → due to bone loss
Plaque Control Record
O’Leary et al. 1972

use disclosing tablets


 Plaque Score (%)=

Number of surfaces with plaque X 100


Number of teeth X 4

Factors that hinder patient’s plaque control:


 Calculus.
 Poor restoration margins.
 Over-contoured restorations.
 Removable partial appliances.
Clinical indicators of occulsal
trauma:
 Mobility (progressive)
 Fremitus
 Premature occlusal contacts.
 Wear facets in presence of other clinical
indicators.
 Tooth migration.
 Fractured tooth
 Thermal sensitivity.

Radiographic indicators of occlusal trauma:


 Widended PDL.
 Bone loss.
 Root resorption.
Radiographic
Assessment
 For radiographic assessment the information
needed is
 Bone Loss

 Horizontal
 Vertical
 Endodontic involvement
 Root deposits
 Root anatomy
 Root length
Periodontal Prognosis
 
Prognosis is a prediction of
the probable course and outcome of a
disease. It is determined following
initial examination, and following
active therapy phase.
Importance:

For Clinician:
 To determine which treatment modalities
will be most effective.
 To develop restorative recommendation
and treatment plans.
For Patient:
 To determine whether treatment seems
worthwhile.
Factors to consider when
assigning a prognosis

 Overall Prognosis 
 Age – younger is worse → fast process
 Medical Status – disease, risk etc
 Rate of progression – chronic vs aggressive
 Patient cooperation
 Knowledge and ability of dentist.
 Etiologic factors – root grooves
 Oral habits – bruxism, damaging contacts
 Should treatment be undertaken?
 Is it likely to succeed?

 When prosthetics are needed are the


teeth in question to support the
additional burden? 
 
Individual Tooth
prognosis: 
 Root form
- Short rooted teeth have worse
crown/root → worse prognosis,
- Fused roots worse than bifurcated
 Caries

- Local risk factor for periodontal disease


 Tooth position
 - Out of alignment has less buccal plate → ↑
recession
 - mesial tilt → harder to clean and treat

 Strategic value

 - Consideration for abutments

 Therapist knowledge and skill.


Periodontal Treatment
Planning
INITIAL THERAPY TREATMENT PLAN
(Phase I therapy)

: Plaque Control Instruction.


Supragingival Removal of Calculus

Recontouring Defective Restorations and Crowns.


Obturation of Carious Lesions & removal of plaque retentive areas
RE-EVALUATION PHASE
Objectives:
 1. To assess tissue response to therapy
a. Gingival Condition.
b. Pocket Depths.
 2. To assess patient’s compliance with OHI
a. Plaque and Bleeding Index
b. Review OHI
 3. To Assess need/advisability for further periodontal
therapies.
 
SURGICAL PHASE
Indications for surgical Phase:.
•Pocket depth.
•Osseous and furcation defects.
•Gingival enlargement.
•Inadequate biologic width.
• Mucco-gingival defects.
• pre-prosthetic plastic Surgery
- Gingival Grafts
- Ridge Augmentation
- Crown Lengthening
MAINTENANCE PHASE

 Objectives

 To prevent the progression and


recurrence of periodontal disease.
 To prevent the loss of dental implants
after clinical stability has been
achieved.
 
 To reduce tooth loss by monitoring the
dentition and any prosthetic
replacement of the natural teeth.
 To diagnose and manage, other diseases
or conditions found within the oral
cavity.
 
 Compliance and its Role in Periodontal
Therapy
 Compliance) has been defined as “ the
extent to which a person’s behavior
coincides with medical or health
advice”.
 
 Compliance in Periodontics: Why
patients fail to comply?
 - Financial reasons

 - Lack of information

 - Time conflicts with job

 - Length of periodontal treatment

 - Chronic nature of the disease


Chapter 1,2 assessment
 What is the information I get from
reviewing the medical/dental history?
 What do I look for in gingival examination?

 What is clinical attachment loss

 What is the index used for assessing


gingival bleeding and the significance of
gingival bleeding?
 What is Glickmans classification for
furcation assessment?
 What does Mucogingival Assessment include?
 What is Miller’s classification for gingival
recession?
 What is Fremitus? How is mobility assessed?
(Scale for Mobility Assessment)
 Which type of radiograph is used for
periodontal treatment and why?
 How can you assess tooth vitality?

 What are the Clinical indicators of occulsal


trauma?
 What are the radiographic indicators of occlusal
trauma
 what is the information needed in radiographic
assessment?
 What kind of information can I get from probing?

 What is the biologic width and its significance?

 What are the gingival biotypes ?