Gingival Health Assessments

Gingival Descriptions

• Healthy gingiva is bright red or pink
• Diseased gingiva is cyanotic (blue) or pigmented
• Healthy gingival contour is knife-edged with pointed interdental papilla
• Diseased gingival contour is rounded/rolled, clefted, bulbous, or festooned
• Healthy gingival consistency is firm and resilient
• Diseased gingival consistency is soft, spongy, or fibrotic, and dents easily with a blunt probe
• Healthy gingival texture is stippled
• Diseased gingival texture is shiny, smooth, or eroded

Calculating Bleeding on Probing (BOP) Percentage

• Each tooth has 6 probing sites: mesiobuccal, midbuccal, distobuccal, mesiolingual, midlingual, and distolingual
• A full mouth exam of 28 teeth has 168 sites (28 x 6)
• Count the number of sites that bleed on probing
• Use the formula: (# of sites with BOP / # of sites recorded on probing)

Gingival Health

• Gingival contour can be localized or generalized
• Gingival contour can be diffuse, marginal, or papillary
• Gingival contour can be slight, moderate, or severe
• Papilla contour can be pointed (healthy), flattened, bulbous, or blunted/cratered
• Marginal contour can be knife-edged (healthy), rounded/rolled, festooned, clefted, or bulbous
• Consistency can be localized or generalized
• Consistency can be diffuse, marginal, or papillary
• Consistency can be slight, moderate, or severe
• Gingival tissue can be firm (healthy), fibrotic, spongy, or soft (indents easily with a blunt probe)
• Texture can be localized or generalized
• Texture can be diffuse, marginal, or papillary
• Texture can be smooth, shiny, eroded (ulcerated), or stippled (healthy)

Gingivitis

• Gingivitis is commonly caused by poor oral hygiene
• Gingivitis is reversible
• Gingivitis causes gums to be inflamed, red, and may cause bleeding

Periodontitis Staging

• Staging informs the clinician of the initial difficulty and complexity of required treatment
• Determine maximum Clinical Attachment Loss (CAL) and Radiographic Bone Loss (RBL)
• Confirm the pattern of bone loss
• Assess periodontitis-related tooth loss
• Determine care complexity, such as furcations, occlusion, or need for extensive treatment
• Stage I is initial periodontitis
• Stage II is moderate periodontitis
• Stage III is severe periodontitis with potential for additional tooth loss
• Stage IV is severe periodontitis with potential for loss of dentition
• The area with the most severe destruction determines the stage

Periodontitis Grading

• Grading assesses the evidence or risk of rapid progression and anticipated treatment response
• Grade A is a slow rate of progression
• Grade B is a moderate rate of progression
• Grade C is a rapid rate of progression

Gingivitis vs Periodontitis

• Gingivitis is a mild, reversible gum disease caused by poor oral hygiene, leading to gingival inflammation and plaque buildup
• Periodontitis develops when gingivitis is untreated, affecting both the gingiva and bone structure, and is nonreversible

Calculating Inadequately Attached Gingiva (IAG)

• Measure the distance from the marginal gingiva to the attached gingiva
• IAG is present only when there is less than 1mm of keratinized attached gingiva
• IAG is only measured on facial/buccal surfaces

Calculating Clinical Attachment Loss (CAL)

• If the gingiva is below the cementoenamel junction (CEJ) (receding), the CAL is positive
• If the gingiva is above the CEJ (inflamed), the CAL is negative
• CAL cannot be negative: it is either 0 or positive
• If the measurement is 0mm past the CEJ, CAL = 0 + probing depth

Recession Example

• Probing depth: 3mm
• Recession: 4mm
• CAL: 7mm

Inflammation Example

• Probing depth: 9mm
• Inflammation: -3mm
• CAL: 6mm

Calculation of Bone Loss

• To find the % of bone loss: (CEJ -> Alveolar ridge / CEJ -> Apex of root) x 100
• If given Apex of root -> Alveolar ridge, subtract it from CEJ -> Apex of root to find CEJ -> Alveolar ridge

Periodontal and Gingival Examination

• Oral biofilm is a risk factor because it is resistant to antibacterial agents and host defense mechanisms
• Stain and calculus do not cause disease but facilitate the retention of oral biofilm
• Establish a baseline at the initial visit and reassess at subsequent visits to monitor progress
• Implement Registered Dental Hygienist (RDH) interventions because assessment is essential for effective care planning and disease prevention
• 50%-90% of the population has periodontal disease

Comprehensive Periodontal Assessment

• Involves probing depth measurements
• Normal molars: 323
• Normal anterior: 212
• Measurements above 4mm with bone loss seen on an x-ray indicate periodontal disease
• Bleeding on probing (%): (Number of sites with BOP / Number of sites probed (6 per tooth)) x 100
• Periodontal Screening and Recording (PSR):
• Re-evaluate a client's periodontal health
• Uses a "WHO probe" with a ball end
• The mouth is divided into sextants, with each tooth scored based on the deepest probing depth using PSR codes
• "The marker" refers to the probe, and CPI stands for Community Periodontal Index, which serve the same function

PSR Codes

• Code 0: Marker is completely visible, no calculus, no bleeding
• Code 1: Marker is completely visible, no calculus, bleeding
• Code 2: Marker is completely visible, calculus, defective margins
• Code 3: Marker is partially visible
• Code 4: Marker is not visible
• *: Indicates a mucogingival defect (furcation involvement, mobility, mucogingival problems, recession)
• Record the asterisk next to the sextant code (0*, 1*, etc.)
• If an abnormality exists in code 3 or 4, a full periodontal exam is required

Presence of Exudates

• Free Gingival Margin Level
• Mucogingival Junction Level
• Tooth mobility
  • Class I: Tooth can move up to 1mm in any direction
  • Class II: Tooth can move more than 1mm in any direction, yet is not depressible in socket
  • Class III: Tooth can move in a buccolingual direction and is depressible in socket
• Fremitus measures vibration/movement during tooth contact by gently applying pressure on cervical 1/3 with an index finger while the client taps teeth together
  • Class I: Mild vibrations or movements
  • Class II: Easily palpable
  • Class III: Movements visible with naked eyes

Tooth Mobility

• Visible mobility is gauged via scale.
• Furcation involvement is also rated via scale.
• Class I: Early involvement

Furcation Involvement

     - Class II: Moderate involvement
     - Class III: Severe involvement
     - Class IV: Complete visualization

• Deposits can be either hard or soft
• Soft deposits removed by brushing and flossing (biofilm)
• Hard deposits removed manually (calculus)
• Gingival Inflammation
• Radiographic evidence of alveolar bone loss

Biofilm and Calculus Assessment Terminology

• Biofilm
• Supragingival calculus: use air, light, visualization, explorer 11/12
• Subgingival calculus: use air, light, visualization, tactile sense, explorer 11/12, radiographs
• Stain (extrinsic/intrinsic)
• Food impactions

Determination of Calculus Amount

• Determined amount can be slight, moderate, or heavy
• Location can be localized or generalized

Extent of Calculus

• Localized affects only a few areas
• Generalized affects a majority of teeth/all

Gingival and Periodontal Assessment

• Utilizes gingival anatomy descriptors
• Described in terms of location and extent

Indices Purpose

• Determine a baseline
• Helps to gather assessment data
• Provides baseline for comparison
• Client education/motivation

Plaque and Gingival Indices Procedure

• Assess plaque and gingiva
• Take six teeth and four surfaces of each tooth.
• Lightly explore how much biofilm is picked up.
• Gently probe gingiva.
• Find total mean divided by the number of teeth scored
• Plaque Index:
• 0: no biofilm
• 1: biofilm adhering to the free gingival margin and adjacent areas of the tooth
• 2: moderate accumulation of soft deposits within the gingival pocket
• 3: abundance of soft matter within the gingival pocket and/or on the tooth and gingival margin

Interpretation of Plaque Index

• 0.0: excellent
• 0.1-0.9: good
• 1.0-1.9: fair
• 2.0-3.0: poor

Gingival Index

• 0: normal gingivae
• 1: mild inflammation – slight change in color, slight edema; no BOP
• 2: moderate inflammation – redness, edema, glazing; BOP
• 3: severe inflammation – marked redness and edema, ulceration, tendency to spontaneous bleeding

Client Analysis

• Teach proper brushing and flossing techniques (modified bass, modified stillmans).
• Teach concepts.
• Teach relationship to oral health education.
• Teach correlation to clinical findings.
• Teach continuing care implications.

Dental Hygiene (DH) Diagnosis

• Human need deficit categories:
• Protection from Health Risks
• Freedom from Pain
• Freedom from Fear and Stress
• Wholesome Facial Image
• Biologically Sound and Functional Dentition
• Skin and Mucous Membrane Integrity of the head and neck
• Conceptualization and problem solving/understanding
• Responsibility for Oral Health

Common Unmet Needs

• Allergies that are unknown/unchecked
• Tooth ache
• High anxiety of the dentist
• Unhappy with their appearance of their teeth
• Broken teeth
• Lesions within the oral cavity
• Unable to afford the full treatment
• Only brushes once a week

Dental vs Dental Hygiene Diagnosis

• Dental diagnosis identifies a specific oral disease, the dentist directs the primary treatment, deals with actual pathophysiological changes, and remains the same for as long as the disease is present
• Dental hygiene diagnosis identifies an unmet human need, within the scope of dental hygiene practice, deals with the client's perception of their own oral status, and may change as the client's response change