Periodontics, 4th year Dr.
Sarhang Sarwat
Diagnosis of Periodontal: Examination, Treatment plan and Prognosis
Diagnostic procedures must be systematic and organized for specific purposes. Diagnosis is of
paramount importance as it does help the clinician to determine etiological and risk factors of the
disease, design appropriate treatment and expect the prognosis.
Periodontal Diagnosis determined by organized analysis of
1- Case history
2- evaluation of clinical signs and symptoms
3- results of various tests such as probing, bleeding assessment, mobility assessment radiograph, blood
test and biopsy.
1- First impression
1- Overall appraisal of the patient
2- Patient attitude, Mental and Emotional status
3- Temperament and Physical age
2- Medical history
A- to protect the patient from any serious systemic complications
B- to protect your self from any contagious diseases
C- To determine any periodontal manifestations of systemic diseases
D- some systemic conditions may exaggerate the periodontal lesion and complicate periodontal therapy
and affect clinical out come of P. therapy.
Medical history must include
1- if the patient is under medical care (nature & duration)
2- if the patient is under drug (type and dosage)
3- hospitalization and surgical operations
4- History of medical problems
A- cardiovascular diseases (uncontrolled hypertension, CVA, MI)
B- Hematological disorders (Anemia, Hemophilia, Leukemia, Decreased platelet count)
C- Endocrine (Diabetes, hyperthyroidism, etc)
D- Infectious diseases (TB infection and pneumonia, V, hepatitis type A, B, C, HIV infection)
5- Possibilities of occupational diseases
6- Bleeding tendency
A- Familial history of bleeding
B- patient under anticoagulant (Warfarin & Aspirin)
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Periodontics, 4th year Dr. Sarhang Sarwat
7- History of allergy (penicillin and other drugs)
8- Information regarding onset of puberty, pregnancy, menopause and menstrual disorder.
9- Patient receiving radiotherapy
Extra oral examination
1. Color of skin, temperature of skin
2. Color of sclera and conjunctiva
3. Any scares and deformities
4. Swelling
5. Palpate the lymph nodes
6. See the lips and angle of the mouth
Examination of lymph nodes
1. Lymph node may become enlarged as a result of
A. Infectious episode
B. Malignant episode
C. Residual fibrotic changes
Inflammatory lymph nodes become enlarged palpable, tender and fairly mobile while malignant
types are mostly painless and fixed
Intra oral examination
1- General look on oral mucosa and the gingiva, roof and the floor of the mouth, cheeks, tongue.
oropharyngeal region.
2- Evaluate the quantity and the quality of saliva
3- Evaluate oral hygiene by assessing plaque, calculus, material alba, food debris, mouth odor, surface
stain, caries and missing teeth.
Examination of the teeth for
1- Caries
2- Developmental anomalies
3- Non carious lesion of teeth
4- Dentine hypersensitivity
5- Proximal contact relation
Wasting of teeth
Wasting or tooth wear; any gradual loss of tooth substance characterized by formation of smoothed
polished surface
Erosion: sharply defined wedge shaped depression in the cervical area of the facial tooth surface,
(smooth, hard, polished surface) caused by acid beverage, citric fruits, acid salivary secretion (chemical
causes)
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Periodontics, 4th year Dr. Sarhang Sarwat
Abrasion: saucer shaped smooth shiny wear at the cervical surface on the cementum rather than enamel
extended to dentine (mechanical wear other than mastication) due to continued exposure to abrasive
material, horizontal tooth brush with highly abrasive dentifrices and action of clasps of removable partial
denture.
Attrition: occlusal wear result from functional contact with opposing teeth.
Dental stain
Are pigments deposits on the tooth carefully examined and determine their origins whether endogenous
(dental fluorosis, devitalized pulp) or exogenous (chromogenic bacteria, food, chemicals smoking stain)
this creates an aesthetic problem and must be separated from dental caries. By proper clinical
examination
Hypersensitivity
Exposed root surface due to gingival recession may be hypersensitive to thermal changes or tactile
sensation they may be located by gentle probing or cold air.
Proximal contact relation
Slightly opened contacts permit food impaction, gingivitis and trauma to the gingiva and pain during
mastication this should be checked clinical observation and dental floss.
Dental History includes
1- Visits to dentist, Frequency, date of most recent visit and treatment received.
2- Tooth brushing, technique frequency, times/day, types of tooth brush, and dentifrices, interval at
which tooth brush changed, use of dental floss or Stimudent.
3- Orthodontic appliance
4- Pain, nature and duration
5- Bleeding gum, spontaneous or on touch
6- Bad taste at areas of food impaction, and bad odor
7- Tooth mobility any difficulties in chewing
8- Habits, grinding and clenching
9- History of previous periodontal problem and treatment performed
Periodontal history
Periodontitis is painless. Patient may aware about
A- Bleeding gum
B- Tooth mobility
c- Spacing between the teeth
D- Foul taste
E- Itching gum
F- Pain of various type and durations
G- Sensitivity with chewing, heat, cold and air application
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Periodontics, 4th year Dr. Sarhang Sarwat
Examination of periodontium Gingiva
Consider the following features
Color, size, contour, consistency, surface texture, position, ease of bleeding and pain distribution and
acuteness or chronicity should be noted.
Clinically gingival inflammation produce 3 basic types of tissue response
1- Edematous: reveal smooth glossy soft, red gingiva resolve by removal of local factors (Sc &P) and good
home care.
2- Fibrotic reaction: usually represents the characteristic of normal gingiva with more firm stippled and
opaque with thicker and more rounded gingiva corrected by surgery (Gingivectomy)
3- Granulomatous reaction: Usually due to frequent irritation to a site with continuous bleeding reveal a
granulomatous reaction known as pyogenic granuloma
Use of Clinical Indices in Dental Practice
Basic periodontal examiantion
Full periodontal assessment
Plaque index
Pocket depth
Bleeding / suppuration
Mobility
Recession
Furcation defects
Vitality tests
Calculus present
Periodontal Screening / Basic Periodontal Examination (BPE)
Code 0 - No bleeding, plaque retentive factors or
pocketing >3.5mm
Code 1 - No pocketing >3.5mm or plaque retentive factors but BOP present
Code 2 - BOP, no PD >3.5mm but plaque retentive factors
Code 3 - PD 3.5-5.5mm
Code 4 - PD >5.5
Code * - Furcation involvement
BPE interpretation
• Should be recorded at least annually for Scores of 0-2
• Score of 3 – full assessment and BPE for other sextants <3
• Score of 4 – full assessment of all sextants
• Score of 3 or 4 usually indicates need for radiographic examination
• Not for assessing treatment outcomes where scores or 3 or 4 were recorded –full assessment
• Maintenance care patients - where scores of 3 or 4 recorded pre- treatment – full mouth probing
depths at least annually
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Periodontics, 4th year Dr. Sarhang Sarwat
Full mouth examination
Plaque index
Score 0= no plaque
Score 1 = presence of plaque
Bleeding index
Score 0= no bleeding
Score 1 = presence of bleeding
Calculus
A. Supragingival calculus detected by naked eyes white creamy to yellowish brown hard deposit above
the FGM, or by a prob.
B. Subgingival calculus not detected by eyes. could be probed by tactile sensation or brown gingival
discoloration or bye x- ray or inflammatory gingival reaction to it
Periodontal pockets
The distance between FGM (changeable point) to Bottom of the pocket, detected by careful exploration
with measuring probe not seen by radiograph because it is a soft tissue measurement.
Clinical Level of Attachment
The distance between CEJ (Fixed Point) and base of the pocket. Change in CAL only be due to gain or loss
of attachment and afford better indication of the degree of the periodontal destruction than Pocket
depth usually do because P. depth may refer to a gingival or false pocket with no periodontal
destruction.
CAL determined by subtracting the distance from FGM to CEJ from pocket depth the result indicates
amount of CAL.
Amount of attached gingiva
Is the distance between MGJ to the gingival groove (Base of the gingival sulcus or base of the periodontal
pocket). This must not be confused with the amount of keratinized gingiva because the later includes
marginal gingiva as well.
The width of attached gingiva is measured by subtracting the sulcus or pocket depth from the whole
gingiva from FGM to MGJ.
The amount of attached gingiva is considered insufficient when stretching the lip induce movement of
free gingival margin.
Normal intersepta
Lamina dura presents as a thin radio opaque border adjacent to and at the crest of interdental septum,
the height of the crest normally 1-2 mm apical to CEJ.
Bone destruction in periodontitis
1- Radiographic image tends to show less destruction than actual at a range from 0-0.6 mm at the crest,
this accounted for x-ray angulations.
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Periodontics, 4th year Dr. Sarhang Sarwat
2- Early sign of periodontitis revealed radiographically as discontinuity of lamina dura at the crest of
alveolar septal bone.
Amount of bone loss
1- Radiograph show amount of remaining bone rather than of bone loss
2- Bone loss is estimated as the difference between physiologic bone level and the height of the
remaining bone.
3- Normal physiologic bone level is between 1-2 mm apical to CEJ.
Distribution and pattern of bone loss
Distribution of bone loss follows location of destructive local factors in different area of the mouth and
along the root surface.
Bone loss: the interdental bone may reduce in height with the crest horizontal to the long axis of the
teeth called horizontal bone loss, or angular to the long axis of the teeth called vertical or angular bone
loss.
Radiograph not reveal the extend of involvement on lingual and facial surface or presence of
fenestration or dehiscence because they will be obscured by the dense root structure. Similarly dense
facial and lingual cortical plate at the interproximal septa obscure the destruction of the intervening
cancellous bone, thus it is possible to have interdental crater without radiographic indications.
Radiographs
As a general guide, radiographs for periodontal assessment will be needed with BPE codes 3, 4 and * to
assess the extent of bone loss. Radiograph used to aid diagnosis and help determine the likely prognosis
of specific teeth when taken together with a comprehensive clinical examination and patient history
Periodontally, radiographs should be assessed for:
1. Morphology of the affected teeth
2. Pattern and degree of alveolar bone loss
3. Monitoring the long-term stability of periodontal health
4. Providing information on other pathologies, such as periapical pathology, pulpal/furcation
involvements and caries, radiographs provide a guide to the overall prognosis of teeth
5. Perio-endo lesions; widened periodontal ligament spaces; abnormal root length or root morphology;
overhanging restorations and presence of subgingival calculus.
Intra oral radiograph
1- 14 periapical Films
2- 4 Bitewing films
Extra oral Panoramic radiograph
Dental panoramic tomographs (DPTs) There is no case for routine screening with panoramic films. The
yield of information is low for screening given the radiation dosage. In complex cases where there are a
variety of dental concerns a DPT could be considered.
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Periodontics, 4th year Dr. Sarhang Sarwat
a- Show the height of the remaining alveolar bone
b- Survey view of the dental arch and surrounding structures
c- Help in detection of developmental anomalies, pathologic lesion, fracture jaw, hidden proximal caries
and impacted teeth
d- Over all view of the severity distribution of bone loss in periodontitis
Periapical vs panoramic radiographs
The choice of panoramic vs. intra-oral periapical radiographs may depend on a range of factors including
preference and availability. In general, full mouth periapical radiographs using a paralleling technique,
give more accurate and detailed assessment of periodontal bony defects.
In contrast, a good quality panoramic radiograph is quicker, less uncomfortable, and may provide useful
assessment of bone levels and other pathologies. Panoramic radiographs might need to be
supplemented with periapical views especially in the anterior sextants due to the likelihood of image
distortion in these regions.
Tooth mobility
Physiologic tooth mobility
Normal, vary from one person to another, from one tooth to another and with same person vary during
day time. At morning more because of slight extrusion of the tooth from its socket then it will be back
after functioning, chewing forces will intrude the tooth again in its socket,
Single rooted teeth show more mobility than multi rooted.
Tooth mobility index
Pathologic tooth mobility is the mobility beyond physiologic range.
Grade 1: Slight more than normal, (0.2-1 mm) horizontal.
Grade 2: More than normal amount more than 1 mm Horizontal.
Grade 3: Sever more than 1mm in faciolingual or mesiodestal with vertical displacement as well.
Causes of T. mobility
1- Bone loss and periodontal tissue support around the tooth (Advanced Periodontitis)
2- Trauma from occlusion: injury produced traumatic occlusal forces or occlusal habits like bruxism and
clenching. Leads to resorption of the cortical plate and widening of PDL spaces
3 External trauma to the teeth lead to fracture or expansion of the alveolar processes of the jaw.
4- Extension of inflammation from the gingiva and apical abscess edema according to hydrodynamic
theory lead to temporary increase in tooth mobility.
5- Periapical surgery extensive bone or root loss at the apex.
Pathologic migration
P. migration plus spacing between the teeth occur due to loss of balance between forces excreted from
the tongue lips and cheek and periodontal and bone support around the teeth due to loss of these
supporting structures that keeps normal balance.
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Periodontics, 4th year Dr. Sarhang Sarwat
Spacing is a late sign of periodontitis. Usually, the tooth moves in a direction opposite to the pocket on
that tooth due to pressure excreted from granulation tissues inside that pocket and retraction of the
tooth by PDL of the opposite site.
Prognosis
Prognosis is the prediction of the probable course, duration, and outcome of a disease based on a
general knowledge of the pathogenesis of the disease and the presence of risk factors for the disease
EXCELLENT: No bone loss, Excellent gingival condition, Good patient cooperation, No systemic /
environmental factors
GOOD: Adequate remaining bone support, Adequate possibilities to control etiologic factors and
establish a maintainable dentition, adequate patient cooperation, No systemic / environmental factors
or if present well controlled
FAIR: Less than adequate remaining bone support, Some tooth mobility, Grade I furcation involvement,
Adequate maintenance possible, Acceptable patient cooperation, Limited systemic / environmental
factors
POOR: Moderate to advanced bone loss, Tooth mobility, Grade I and II furcation involvement, Difficult to
maintain areas, Doubtful patient cooperation, Presence of systemic / environmental factors
QUESTIONABLE: Advanced bone loss, Grade II and III furcation involvements, Tooth mobility,
Inaccessible areas, Presence of systemic / environmental factors
HOPELESS: Advanced bone loss, Non-maintainable areas, Extractions indicated, Uncontrolled systemic /
environmental conditions
Determination of prognosis
Prognosis: Is a prediction of the duration, course and termination of disease and its response to
treatment.
Prognosis of gingivitis
Is favorable if inflammation is the only pathologic change, providing that all local factors entirely
removed and patient provide good home care in maintaining proper oral hygiene. if gingivitis is
complicated by systemically caused tissue change, gingival health could only be achieved temporarily via
local therapy alone.
But long term prognosis depend on correction of systemic factors.
Prognosis of periodontitis
Slowly progressive periodontitis
More common attack 30th and 40th progress slowly responding well to conventional treatment provided
that they are not very severe and local irritation can be controlled (prognosis related to the severity of
the disease and height of remaining bone) accordingly prognosis is made and its fair to good in general
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Periodontics, 4th year Dr. Sarhang Sarwat
Rapidly progressive periodontitis
Less common, attack 20th exhibits rapid bone loss with slight inflammation and marked bone
destruction, or sever inflammation leads to rapid bone loss.
Prognosis usually poor because it is associated with
1- Plaque with high periodontal pathogens
2- leukocyte dysfunction and combined with systemic conditions.
Some cases of Rapidly Progressive P. are responsive to conventional therapy plus antibiotics, but not all
types.
Refractory periodontitis
Refractory periodontitis: refer to cases that resist to conventional therapy because of
1- impaired defense mechanism
2-resistant bacteria
3- root morphologic abnormality that makes proper root planning not possible.
4- Or combination of these factors.
Factors that may influence the overall prognosis
A. Systemic factors
Patient age, Current severity of disease, Systemic factors, Smoking, Presence of plaque & calculus,
Patient compliance and Prosthetic possibilities.
AGE: Comparable connective tissue attachment and alveolar bone – prognosis better for older vs
younger patient due to a shorter time with more periodontal destruction.
BONE LOSS: Horizontal bone loss depends on the height of the existing bone.
Angular defects - if the contour of the existing bone & the number of osseous walls are favorable, there
is an excellent chance that therapy could regenerate bone to approximately the level of the alveolar
crest.
Habit: Smoker tend to respond less favorably to periodontal treatment
PATIENT COMPLIANCE & COOPERATION: Refuse to accept the patient for treatment and extract teeth
with hopeless or poor prognosis and perform scaling and root planing on remaining teeth
SYSTEMIC DISEASE/ CONDITION: Prevalence and severity of periodontitis - significantly higher - type I
and II diabetes. Prognosis dependent on patient compliance relative to both dental and medical status.
Well controlled patients - slight to moderate periodontitis - good prognosis
B. Local factors
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Periodontics, 4th year Dr. Sarhang Sarwat
PLAQUE AND CALCULUS: Bacterial plaque and calculus - most important local factor in periodontal
diseases. Good prognosis- depends on ability of patient and clinician to remove etiological factor.
SUBGINGIVAL RESTORATIONS AND POOR DISGNED DENTAL PROTHESIS: Contribute to Increased plaque
accumulation, Increased inflammation, Increased bone loss Subgingival margins - poor prognosis.
ANATOMIC FACTORS: Short, tapered roots with large crowns, cervical enamel projections (ceps) and
enamel pearls, intermediate bifurcation ridges, root concavities, and developmental grooves -
predispose periodontium to disease, Teeth with short, tapered roots and relatively large crown – Poor
prognosis
TOOTH MOBILITY: caused by Principal causes, Loss of alveolar bone, Inflammatory changes in the
periodontal ligament and Trauma from occlusion.
Stabilization by use of splinting - beneficial impact on the overall and individual tooth prognosis.
CARIES, ABUTMENT SELECTION NON-VITAL TOOTH AND TOOTH WITH ROOT RESOPTION:
They usually have poor prognosis comparing with tooth without these conditions
Prognosis of individual tooth
Depend on
1- Grade of mobility
2- Depth of the pocket and CAL
3- Presence or absence of mucogingival problems
4- Furcation involvements
5- Tooth morphology
6- Location of remaining bone in relation to individual root surface
7- Caries, non vital tooth and root resorption
Treatment plan
Must includes:
1- Procedures required for establishment and maintenance of oral health
2- Decision regarding teeth to be treated or extracted
3- Decision on techniques to be used in pocket elimination
4- Decision on need for mucogingival surgery or occlusal correction
5- Planning for unexpected developments during treatment may necessitate modification of treatment
plan.
Treatment plan
The primary goal for the treatment plan is to achieve well functioning dentition in a healthy periodontal
environment, this will be created by elimination of gingival inflammation and correction of periodontal
condition by
1. Elimination of root irritants
2. Pocket elimination
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Periodontics, 4th year Dr. Sarhang Sarwat
3. Establishment of gingival contour
4. Proper mucogingival relationships that preserving periodontal health
5. Restoration of carious teeth or correction of existing restorations
6. Occlusal, restorative, orthodontic and prosthetic procedures must be performed for better result of
periodontal therapy
7. Splinting plus correction of bruxism and clenching habits
8. Systemic conditions must be evaluated for precaution and modification of periodontal therapy
9. Supportive therapy for maintaining the periodontal health after therapy
Good luck
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