‫بسم اهلل الرحمن الرحيم‬

Diagnosis in perio clinic

Mohanad H.Sharif

Here I will talk about the two diagnosis we are concerned with in the
perio clinic (gingivitis and periodontitis), any other diagnosis is clear
e.g. the patient may come complaining of aggressive periodontitis or
pemphigus vulgarize or drug induced gingival enlargement and so on.
What about gingivitis and periodontitis?

Please note that each of these two diagnosis consist of 4 parts, any
missing part(s) will make you lose marks so make sure that you write
the full diagnosis, these parts are :

A. For gingivitis:

Generalized Marginal Acute gingivitis

localized Papillary chronic
diffused
B. For periodontitis:

Generalized Mild chronic periodontitis

localized Moderate
sever

1. gingivitis or periodontitis:
A. Gingivitis:

We know gingivitis by what we call gingival index (bleeding index), it

has 4 grades:

 Grade 0: no bleeding or signs of inflammation (i.e. normal).

 Grade 1: there are signs of inflammation (e.g. change in color or
loss of stippling), but there is no bleeding.

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  Grade2: there is bleeding on probing (you may have to wait up to
15sec after probing for the blood to occur).
 Grade 3: there is spontaneous bleeding.

Only grade 0 is considered normal, grade 1, 2 and 3 are all gingivitis,

most of you ignore grade 1 and only consider grade 2 and 3, please
remember that any loss of stippling or change in color is also gingivitis
even if there is no bleeding so make sure you look for them as well.

B. Periodontitis:

We know periodontitis by its clinical features, there are two types of

clinical features:

i. Major clinical features:

These are Pocket and bone loss.
ii. Minor clinical features:
There are many minor clinical features the most important
are:
 Mobility.
 Recession.
 Pathological tooth migration.
 Halitosis.

Note:

 Pocket: from the gingival margin to the base of the pocket.

 Attachment loss: from the CEJ to the base of the pocket.
 Recession: from the CEJ to the gingival margin.

How can you diagnose?

If a patient came with one or more of the major clinical features this is
considered as periodontitis, even if there is no minor clinical features.
However if there is only minor features it need an experience clinical
judgment to say it is periodontitis.

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Note:

False pocket is not considered periodontitis (e.g. pocket due to gingival

enlargement), only true pocket does. On the other hand iatrogenic (by
operator scalpel) or traumatic (e.g. by tooth brushing) attachment loss
are also not considered as periodontitis.
2. Acute or chronic?
First: there is no acute periodontitis.
Second: there are only 8 acute gingival conditions these are:
 Acute necrotizing ulcerative gingivitis (ANUG).
 Acute Herpetic gingivostomatitis.
 Pericoronitis.
 Recurrent aphthous ulceration (RAU).
 Oral candidiasis.
 Gingival abscess.
 Traumatic gingival lesion (thermal, chemical and
mechanical).
 Hypersensitivity reactions (allergic reactions).

So there is no acute periodontitis and the previous 8 conditions are the

acute gingivitis. So the rest are either chronic gingivitis or chronic
periodontitis.
3. Generalized or localized:
 Gingivitis:
We use the following formula:
No of teeth with gingivitis x 100%

Total No of teeth present in the oral cavity

If it is less than 30% it is localized, if it is 30% and more it is generalized.

 Periodontitis:
We use the following formula:
No of teeth with periodontitis x 100%
Total No of teeth present in the oral cavity

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If it is less than 30% it is localized, if it is 30% and more it is generalized.
4. For gingivitis: marginal, papillary and diffused:
 Marginal: the inflammation affects the marginal gingiva only.
 Papillary: the inflammation affects the interdental papilla only.
 Diffuse: the inflammation affect the marginal, attached and the
interdental papilla.
5. For periodontitis: mild, moderate and sever:
a) If there is no recession: i.e. the CEJ is not visible (i.e. there is a
pocket but the CEJ is not exposed yet) we cannot say mild,
moderate or severe so here the diagnosis will consist of only 3
parts:

Generalized chronic periodontitis

localized

b) If there is recession: i.e. the CEJ is visible we use the attachment

loss (called clinical attachment loss [CAL] or probable attachment
loss [PAL] and measured from the CEJ to the base of the pocket)
and if it is:
 1-2mm: mild.
 3-4mm: moderate.
 5 and more: sever.
So here the diagnosis will consist of 4 parts:

Generalized Mild, chronic periodontitis

localized moderate or
sever

Note:

If the patient has mild in some teeth, moderate in some teeth and
sever in others you have to write them all. E.g. the patient may have

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 generalized chronic periodontitis mild in 12 moderate in 56 and
sever in 7

And finally: how to write the diagnosis?

Again Remember each diagnosis (gingivitis and periodontitis) consist of

4 parts (except when the CEJ is not visible in the presence of pocket in
periodontitis [see no 5 (a) in page 4]):

1. When only one of them present the diagnosis is usually straight

forward, it is either:

Generalized Marginal Chronic Gingivitis

localized Papillary Acute ( if it is one
diffused of the 8 acute
conditions)

Or

Generalized Mild chronic periodontitis

localized Moderate
sever

But localized periodontitis usually present with generalized gingivitis

i.e. the patient is rarely come with a diagnosis localized chronic
periodontitis alone (see no 3 below).

2. When generalized periodontitis present we only write it without

gingivitis (i.e. we don’t write generalized periodontitis with
localized gingivitis) so the diagnosis is:

Generalized Mild chronic periodontitis

Moderate
sever

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 3. When gingivitis occur with localized periodontitis, the diagnosis
will consist of 8 parts:

Generalized Marginal Chronic Gingivitis

localized Papillary Acute ( if it is one
diffused of the 8 acute
conditions)

With

Mild chronic periodontitis

localized Moderate
sever
But with any localized you need to write the teeth involved

E.g. generalized marginal chronic gingivitis with localized

moderate chronic periodontitis in 34

Note:

Two important things you need to know:

First: localized gingivitis is extremely rare and usually- if

present- it indicates specific problem in that area so unless you
are 100% sure it’s localized don’t write it (remember change in
color and loss of stippling are also gingivitis).

Second: although diffused gingivitis is present it is rare for the

inflammation to extend to the marginal, interdental papilla and
the attached gingiva without causing pocket or bone loss so
again if you are not 100% sure it is diffused just write marginal
gingivitis because it is the most common one.

The end

‫تم بحمد اهلل‬