2. Chapter outline :
❖ Overall appraisal of the patient
❖ Health history
❖ Dental history
❖ Photographic documentation
❖ Clinic examination
❖ Tactile periodontal examination
❖ Periodontal charting
❖ Examination of the teeth & implant
❖ Radiographic examination
❖ Periodontal diagnosis
❖ Assessment of biofilm control & patient education
❖ Conclusion
3. Introduction
❖ Periodontal diagnosis : is determined after carefully analysis of
the case history and evaluation of clinical signs and symptoms as
well as the result of various diagnostic procedures ex , ( probing ,
mobility assessment , radiograph , and blood test )
❖ Diagnosis must include general evaluation of patient & a
consideration of the oral cavity
4. Sequence of procedures for the diagnosis of periodontal
diseases :
Overall appraisal of the patient
Health history
Dental history
Chief complain and current illness .
5. Sequence of procedures for the diagnosis of periodontal
diseases :
❖ Photographic
documentation
❖ Initial photograph should be
taken before the tissue is
probed and manipulated to
obtain an undisturbed
baseline of the patient mouth
with gingiva and biofilm
intact .
6. Sequence of procedures for the diagnosis of periodontal
diseases :
❖ Clinical examination
1. Examination of extra oral structure
❖ TMJ , muscle of mastication , lymph node .
3. Examination of the oral cavity
❖ The cleanliness of the oral cavity is appraised in term of accumulated food debris , biofilm , calculus , and
tooth surface stain , as well as biofilm coating of the dorsum of the tongue .
.
4. Examination of the periodontium
❖ Consist of two part : visual examination and tactile examination .
5. Visual periodotal examination
❖ Begin with drying of the tissue and taking survey of biofilm and calculus accumulation to assess oral hygiene
as well as clinical signs of inflammation and recession to assess the severity of diseases .
7. Continue with Clinical examination
‣ 5. Visual examination of biofilm and
calculus
‣ Biofilm and Supra gingival calculus
The presence of biofilm and supra gingival
calculus can be absorbed directly .
It is commonly accumulates on lingual
surface of mandibular anterior teeth and
buccal surface of maxillary molar .
‣ Biofilm and Subgingival calculus ,
‣ its not easily detected , most of the time it
will need to be detected by carful probing
of the root surface .
8.
9. 6. Visual examination of the gingiva
❖ Periodontal examination begin with the visual evaluation of the gingival margin for
the presence of tooth surface accretion and inflammatory change in gingiva
❖ Gingiva is keratinized collar of masticatory mucosa around the teeth , and it is
extend from mucogingival junction to marginal gingiva
❖ Gingival recession, the location of gingival margin around teeth should be evaluated
and recorded , especially when recession is present . In the absence of attachment loss
, the gingival margin is located coronal to cement-enamel junction .
10.
11. Sequence of procedures for the diagnosis of periodontal
diseases :
❖ Tactile periodontal
examination
1. Tactile examination of the marginal
gingiva
❖ Marginal bleeding evaluated by
running the probe around the gingival
margin
12. ❖ Suppuration
❖ palpation of marginal
gingiva with a probe or by
placing the ball of index
finger on the gingival
apical to the margin , and
pushing coronaly toward
gingival margin may
squeeze a white yellowish
exuadate from the gingival
crevice .
13. Continue ;
Tactile periodontal examination
2. Tactile examination of gingival crevice
When proofing , the probe tip should be in contact with the tooth
surface as it slide down along the tooth surface to get to the
bottom of the gingival service . This allow detection of the tooth
surface irregularities , furcation invasion , and sub gingival
calculus .
❖ Probing around implant , implant is susceptible to biofilm induced
inflammatory diseases . Traditional probe under light force ( o.25 n )
without damaging the preimplantation mucosal seal
❖ When not to probe , in the presence of overt and obvious
periodontal disease , it may be best to delay accurate probing depth
measurement until the scaling and root planing appointment , when
the tissue is anesthetized .
❖ Probing depth , there are two different pocket depth (1) the biologic
or histologic depth and (2) the clinical or probing depth.
❖ Probe penetration dependence ;
14. ❖ Automatic and electronic periodontal probing ,
Accuracy and reproducibility depend not only on root morphology and tissue
changes but also, importantly, on the probing technique, the probing force, the size
of the probe, the angle of insertion of the probe, and the precision of the probe’s
calibration.
❖ Probing force
A force of 0.75 N. has been found to be well tolerated and accurate.With forces of up
to 30g, the tip of the probe remains within the junctional epithelium, whereas forces
of up to 50 g are necessary to reach the bone level.
❖ Probe angulation
❖ Probe angulation is parallel to the long axis of the tooth
❖ Interproximally angulation , slightly tilted . Apical to the contact point
15. Continue ;
❖ 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 test
❖ Pain on probing , pain is cardinal sign of inflammation . Gingival inflammation and periodontal disease in
general are painless .
❖ Attachment loss ,it is the apical migration of dentenogingival junction - the periodontal attachment apparatus -
as a result of the inflammatory response .
❖ It is measured as the distance from the cement-enamel junction the bottom of the probeable crevice
‣ When Gingival margin is located on the anatomic crown , CAL determined by subtracting the distance from
the gingival margin to the cement-enamel junction from the probing depth .
‣ When gingival margin coincide with CEJ , CAL is equal to probing depth
‣ When gingival margin located apical to CEJ , CAL is greater the probing depth
‣ Therefor clinical attachment loss , or distance between the CEJ and the bottom of the probeable crevice , is the sum
of gingival recession and probing depth
‣
16. ❖ Attachment level measure the distance
between attachment level and a reference
point on a tooth , such as CEJ . Change in
the attachment level can result of gain or
loss of attachment .
❖ Attached gingiva , the width of attached
gingiva is the distance between
mucogingival junction and the projection
on the external surface of the bottom of the
gingival sulcus or periodontal pocket
‣ The width is determined by subtracting the
sulcus or pocket depth from total width of
the gingiva .
Continue ;
17. Sequence of procedures for the diagnosis of periodontal
diseases :
❖ Examination of the
teeth and implant
❖ Wasting disease of the teeth
Wasting is defined as gradual loss of
tooth substance , which is characterized
by the formation of smooth , polished
surface without regard to the possible
mechanism of this loos .
18. Sequence of procedures for the diagnosis of periodontal
diseases :
❖ Periodontal charting
1.Use of clinical indices in dental practice , the gingival index and the sulcus bleeding index
appear to be the most useful and most easily transferred to clinical practice
2.Periodontal pocket
- include their presence and distribution on each teeth surface
Signs and symptoms as a color change , “ rolled “ edge separating the gingival margin from the
tooth surface , enlarged or edematous gingiva , the presence of bleeding , suppuration and loose ,
extruded teeth may denote the presence of a pocket
Detection of periodontal pocket , “ probe “ .
3.Determination of disease activity
There are no accurate methods to determine the activity or inactivity of the lesion .
19. Continue of Periodontal charting
4- Alveolar bone loss , probing is helpful
to determine the hight and contour of the
facial and lingual bone and the
architecture of interdental bone
• Trans gingival probing which is
performed after area is anesthetized , is
more accurate methods of evaluation ,
provide more information about bone
architecture .
20. 5- Furcation invasion , the pathologic
resorption of interdental bone within a
furcation of a multirooted tooth due to
periodontal disease .
The Glickmann Classification :
(I) Grade I : pocket formation into the
flute but intact interradicular bone
(II)Grade II : loss of interradicular bone
and pocket formation of varying
depth into the furcation but not
completely the to the opposite side of
the tooth
(III)Grade III : through- and through
lesion
(IV)Grade IV : same as grade III with
gingival recession , rendering the
furcation clinically visible .
21. Continue of Periodontal charting
6- Periodontal abscess , it is a localized accumulation of exudate with the gingival wall of a periodontal pocket .
✓ Acute periodontal abscess
✓ Chronic periodontal abscess
7 Periodontal abscess and gingival abscess
✓ The principal differences between them are the location and history .
✓ Periodontal abscess , involve the supporting periodontal structure and occurs generally on chronic
destructive periodontitis
✓ Gingival abscess , confined to the marginal gingiva , and often occurs in perviously disease - free areas .
8- Periodontal abscess and periapical abscess
✓ If the tooth is non vital ( periapical abscess )
✓ When the apex and lateral surface of a root are involve with single lesion that can be probed directly from
gingival margin ( periodontal abscess )
✓ Radiographic finding :
✓ radiolucent area along the lateral surface ( periodontal abscess )
✓ Whereas apical rarefaction ( periapical abscess )
22. Continue of Periodontal charting
9- Dental stain , they are pigmented deposit on the teeth , that should be clearly
examined to determine their origin .
10-Hypersensitivity , root surfaces exposed by gingival recession may be
hypersensitive to thermal changes or tactile stimulation. Located by gentile exploration
with a probe or cold air .
11-Proximal contact relation , open contact allow food impaction . The tightness of
contacts should be checked by means of clinical observation and with dental floss
12- Sensitivity to percussion , it is a features of acute inflammation of periodontal
ligaments , its help in localization of the site of inflammatory involvement .
23. Continue of Periodontal charting
13-Tooth mobility
It is occurs in two stages :
1- the initial stage , occurs when the tooth moves
within the confines of periodontal ligaments
2- the secondary stage , occurs gradually and entails
elastic formation of the alveolar bone in response to
increases horizontal forces .
Mobility is scored according to Miller Index as
follow :
• Mobility no. 1 : first distinguishable sign of
movement greater than normal
• Mobility no. 2 : movement of crown up to 1mm
in any direction .
• Mobility no. 3 : movement of the crown more
than 1mm
Factors affecting mobility : periodontal
inflammation , attachment loss and occlusal trauma
24. Continue of Periodontal charting
15- truma from occlusion , it is refer to tissue injury produced by occlusal force rather than the occlusal forces themselves .
The periodontal finding that suggest presence of trauma from occlusion include :
Excessive tooth mobility , vertical or angular bone destruction , pathologic migration .
16- pathologic migration of the teeth
Alteration in the tooth position should be carefully noted , identifying abnormal force , a tongue thrusting habits , or other
habits that may be contributing factors
14- Dentition with the jaws closed , can detect conditions such as irregular aligned teeth , exuded teeth , improper proximal
contact , and area of food impaction , all of which may favor plaque accumulation .
• Overbite
• Open bite relationship
• Cross bite
17- Functional occlusal relationship
The examination of it is an important part of diagnostic procedure . Dentition that appear to be normal when the jaws are
closed may present marked functional abnormalities
25.
26. Sequence of procedures for the diagnosis of periodontal
diseases :
❖ Radiographic
examination
27. Sequence of procedures for the diagnosis of periodontal
diseases :
Laboratory aids to clinical diagnosis
• When unusual gingival or periodontal problems are detected that cannot be
explained by local causes, the possibility of contributing systemic factors must be exp
• laboratory tests aid in ;
❖ Analyses of blood smears,
❖ blood cell counts,
❖ white blood cell differential counts,
❖ and erythrocyte sedimentation rates
❖ are used to evaluate the presence of blood dyscrasias and generalized infections..
28. Sequence of procedures for the diagnosis of periodontal
diseases :
Periodontal diagnosis
1- what is the disease ?
2- how sever is the disease ?
3- what is the extent of the disease ?
Disease that can affect the periodontium are listed in the classification of periodontal diseases and condition .
• Severity of disease is classified based on a three- tier system
• The extent of the disease
• Biofilm - induced inflammatory periodontal disease are diagnosed based on the presence of inflammation and
attachment loss ( biofilm induced gingivitis + chronic periodontitis )
• The severity of chronic periodontitis is characterized on three tier system based on CAL . ( INADEQUATE )
• The extent of chronic periodontitis biofilm induce gingivitis is delineated based on the 30% threshold .
( localized + generalized )
29. Sequence of procedures for the diagnosis of periodontal
diseases :
❖ Assessment of biofilm control and patient
education
Patients should be given personalized oral hygiene instructions to control biofilm and to
improve their oral health and the conditions of the periodontium. It is not uncommon
for patients to report brushing and flossing multiple times daily, while having poorly
controlled periodontal disease in their mouths. For that reason, the effectiveness of the
patient s bio lm control must be evaluated. The patient should be asked to demonstrate
bio lm control toothbrushing, flossing, etc., in front of a mirror so that both the patient
and the clinician can see his or her oral hygiene techniques.
30. Conclusion
❖ Examination → Diagnosis → Prognosis ↔ Treatment
✤Diagnosis require through and carful examination
✤Prognosis is based on accurate diagnosis
✤Treatment decisions are based on prognosis
✤Treatment decisions are made to improve prognosis
✤Diagnosis and prognosis will change with treatment
