Periodontal Diagnosis and Health History

• Intelligent treatment demands proper diagnosis.
• Periodontal diagnosis involves determining disease presence, identifying the disease and its severity, and understanding its causes.
• Periodontal diagnosis comes after case history analysis, clinical signs evaluation, diagnostic procedures.
• Focus on the patient with the disease, not just the disease itself.
• Diagnostic procedures must be systematic and organized.
• Patient appraisal includes mental and emotional status, temperament,attitude, and physiologic age.

Health History

• Most of the health history occurs at the first visit and is supplemented later.
• Health history can be obtained verbally via questioning and recording the patient's responses.
• Health history can be obtained via questionnaire the patient completes.
• Explain the importance of health history clearly, because patients often omit information they don't relate to dental problems.
• Patients should know the possible effect of systemic diseases, conditions, behavioral factors, and medications on periodontal disease, its treatment, and outcomes.
• Patients should know conditions present that may require special precautions or procedure modifications.
• Patients should know oral infections may powerfully influence systemic diseases and conditions.
• Health history should reference the date of last physical exam, frequency of physical exams, and physician visits.
• If the patient is under a physician's care, discuss the nature, duration, and therapy of the problem.
• Record the physician’s name, address, and phone number, because direct communication may be necessary.
• Details regarding hospitalizations and operations, including diagnosis, type of operation, and any untoward events, should be obtained.
• Inquire about all medical problems like cardiovascular, hematologic, endocrine, infectious diseases, sexually transmitted diseases, high-risk behavior for HIV, and possible occupational disease.
• Note abnormal bleeding tendencies like nosebleeds and prolonged bleeding from minor cuts.
• Mention spontaneous ecchymosis and excessive menstrual bleeding.
• Correlate these symptoms with the patient's medications.
• Information for females about the onset of puberty, menopause, menstrual disorders, hysterectomy, pregnancies, and miscarriages.
• Include a list of all medications taken, prescribed or over-the-counter.
• Analyze the possible effects of medications to determine their effect on oral tissues and avoid administering medications that would interact adversely.
• Special inquiry should be made regarding the dosage and duration of therapy with anticoagulants and corticosteroids.
• Caution patients taking bisphosphonates for osteoporosis about possible problems related to osteonecrosis of the jaw after oral surgery.
• The patient allergy history should be taken including hay fever, asthma, sensitivity to foods, drugs, and dental materials.
• Take a family history, including bleeding disorders, cardiovascular disease, diabetes, or periodontal diseases.
• Gather detailed information on alcohol, recreational drugs, tobacco use, and desire to quit.
• Obtain baseline vitals, including blood pressure.
• Medical consultation is required before treatment for patients on medications or patients who don't know the control of their systemic disease.

Dental History

• Dental history should reference visits to the dentist, including their frequency, date of the recent visit, nature of the treatment, and dental prophylaxis.
• Reference periodontal maintenance or scaling and root planing by a dentist or hygienist, cleaning frequency and date of recent cleaning.
• Describe the patient's oral hygiene regimen, including toothbrushing frequency, time, method, type of toothbrush and dentifrice, and interval when brushes are replaced.
• Other methods for mouth care, include mouthwashes, interdental brushes, other devices, water irrigation, and dental floss.
• Note any orthodontic treatment including its duration and the approximate date of termination.
• Describe the manner in which pain is provoked, its nature and duration, and the manner in which it is relieved, for any pain the patient is experiencing in the teeth or in the gingiva.
• Note the presence of any gingival bleeding including when it first occurred; whether it occurs spontaneously, on brushing or eating, at night, or periodically.
• Note if bleeding is associated with the menstrual period or other specific factors; and its duration of bleeding and the manner by which it is stopped.
• A bad taste in the mouth and areas of food impaction should be mentioned.
• Assess if the patient's teeth feel loose or insecure, if he or she has any difficulty chewing, and tooth mobility.
• Note the patient's general dental habits like grinding during the day or night.
• Discuss the patient's history of periodontal problems, including nature of the condition and the treatment received.
• Note if the patient wears a removable prosthesis and if it's a detriment or enhancement to existing dentition/tissue.
• Document if the patient has implants.
• Periodontal examination and diagnosis must include obtaining a thorough health/dental history.
• Digital photographs are important for record-keeping, education for clinician/patient, communication, and planning.
• Photographs provide details clinicians might forget.
• Photographs allow for evaluation of the mouth and monitoring changes.
• Take intraoral photos prior to probing to obtain baseline of biofilm and gingiva intact.
• Initial photographs should be taken before tissue probe.

Clinical Exam

• Clinical exam begin with extraoral structures evaluation for abnormalities.
• Assess the temporomandibular joints for pain, crepitus, clicking, and range of motion.
• Palpate the muscles of mastication for pain and tenderness.
• Because periodontal, periapical, and other diseases may result in lymph node changes, examine and evaluate the lymph nodes of the head and neck.
• Lymph nodes can enlarge due to infection, malignant metastases, or residual fibrotic changes.
  • Inflammatory nodes become enlarged, palpable, and tender, with red/warm surrounding skin.
  • Primary herpetic gingivostomatitis, necrotizing ulcerative gingivitis, and acute periodontal abscesses cause lymph node enlargement.
• Lymph nodes return after successful therapy.
• Carefully examine the entire oral cavity, beginning with brushing and oral hygiene habits.
• Appraise cleanliness in terms of accumulated food debris, biofilm, calculus, and tooth surface stains, as well as biofilm coating on the tongue's dorsum.
• Oral malodor: the foul odor emanating from the oral cavity.
• Evaluate abnormalities and pathologies of the lips, floor of mouth, tongue, palate, vestibule, and the oropharyngeal region.
• Palpate the oral mucosa in the lateral/apical areas for periapical and periodontal tenderness/abscesses.
• The periodontal examination should be systematic.
• The periodontal exam should not immediately begin with the periodontal probe into crevice.
• Probing of the gingival crevice is uncomfortable and make inflammation challenging to view.
• Periodontal disease results from biofilm accumulating and adjacent tissue responding.
• Thorough, careful visual gingival margin evaluation to assess biofilm and calculus accumulation, as well as inflammatory changes.
• Thorough probing of the gingival crevice and the surrounding tissue provides valuable information essential to the diagnosis and treatment of periodontal disease.
• Examination of the periodontium involves visual and tactile examinations.
• Visual examination begins with drying the tissue and surveying biofilm/calculus to assess oral hygiene and clinical inflammation/recession signs.
• Many methods assess biofilm and calculus accumulation.
• Observational examination of biofilm and supragingival calculus can be observed directly.
• Biofilm frequently accumulates along the gingival margins and in embrasure spaces, especially distal surfaces and lingual mandibular molars.
• Supragingival calculus accumulates on lingual mandibular anterior teeth and buccal maxillary molars surfaces because of salivary ducts and ineffective biofilm removal.
• Biofilm on buccal and facial surfaces near the midline are accessible for removal.
• Its presence suggests inadequate oral hygiene.
• Biofilm presence correlates to severity of gingival inflammation.
• Subgingival calculus isn't detected easily; probing detects subgingival.
• Soft tissue changes can provide clues to the location of subgingival calculus.

Gingival Exam

• Shallow subgingival calculus becomes visible if soft tissues are thin.
• Mucogingival: determined by stretching the lip and cheek or rolling in vestibule.
• Evaluation of the gingiva: the tissue needs it must be dried to see it.
• The gingiva: The keratinized collar of masticatory mucosa around the teeth.
• On the palate- the gingiva extends apically from the mucogingival junction.
• The width of the gingiva: The distance from the mucogingival junction to the gingival margin.
• In the presence of inflammatory:
  • Red or cyanotic color.
  • Rolled margins with bulbous papillae.
  • Smooth and swollen gingiva.
• With physiologic pigmentation: -Gingiva can be pigmented and dark. -If healthy gingiva is associated with inflammation
• Gingival Recession- should be determined around teeth.
• The location of the gingival margin is coronal in the absence of loss.
• Recession is the distance from the gingival margin, if its supragingival.
• Recession indicates attachment loss.
• Assess the amount of recession & related factors.
• Stippling is varied among individuals.
• The periodontal needs visual evaluation of the margin, presence of calculus and changes.
• Tissue will be fibrotic with chronic inflammation in smokers.
• With Inflammatory change = marginal bleeding. -Use a probe to test by running along the margin.
• Healthy tissue = will be blanched without blood.
  • Inflamed = bleeding.
• The ease of bleeding correlates with the severity of gingival inflammation
• Purulent exudates can be expressed by digitally pushing on the margin.
• Suppuration doesn't occur in the pockets, but can be revealed with pressure.
  • Absent suppuration doesn't mean absence of disease.
• The probe is inserted vertically into the gingival crevice to the bottom -"Walk" the probe around the surface. -Pay attention to the gingval and tissue

Probing Depths

• Healthy = will feel tight and resist. Adhesion of the junctional epithelium stops in healthy.
• Tissue probe = Severely inflammed tissue might not have resistance. Probing and hard surfaces are rough on the surface. Calculus impairs with probing.
• Probe needs to move axially.
• Calculus associated with tissue change, absense of tightness.

Further Probing facts

• When using a probe it needs to slide in contact with the bottom of the pocket Detection of calculus must be on the probe Defects are paired with deep probing and Gingival inflammation
• Probe placements- Oblique- Detectinterdential craters
• Specially designed probes help with exploring furtcation
• Instrumental to instruments accurate- probe calculus and measure it Thoroughly probe to treat diagnoses and periodontal disease

Implants and when not to probe

• Must probe and diagnosis due to diseases. Traditional probe can be used under low pressure. In inflamation it's diffiuclt to obtain wihout aesthesia
• When disease is obvioua wait until anestheized Cases that require root planet- delay probe until appoitment Depths change improving biofilm change and root planing.
• As such its more important the post treatment probing
• General Probes
  • 3mm or less is healthy
  • Greater is inflammation

Probe insertion levels

• Biologic or Histologic
  • Margin and based
  • Can only be measured with adequetly aligned histologic sections
• Clinical
  • the distance of margins Biological pokcets = Normal sulcus

Automated Probing

The use helps detect more than just loss, but attachment and depth as well. The force is variable to people probing

Affects of Probing Standardization

• Root
• Change
• Technique
• Force Identifying Junctions are difficult, but essential

Bleeding of Probing

• Ulcerated gingiva and epithelim
• Not in non-inflammed sites
• A sign of gingival changes

Severity of Bleeding

• Range from red lines to bleeding and success can stop it. Move laterally along the pocket or the immediate delay. Not a good predictor, only indicatior.
• It's cardinal to diagnosis. Tissue probes General probing doesn't.
• Attachments are where the tissues begin coronal.
• With attachments and cementum, tissues become exposed.
• The level shows measured loss.
• Can Be recorded with clinicals . Shallow attached to 3rd level are worse that cornoal third level.

Gingiva that it attached

The width is the distance, but if the lip moves the attached if insufficient.

• With dull instrument is one way to measure
• Solution Stains

Clinical Chariting

Used for the findings associated and treatment response. Chart and record with electronics for quick and rapid assess or x ray

• The gingival and sulcus can be the cause. If the both are same clinical shows attachment. At the margin of clinical attachment shows probing and loss.
• Gain a loss is the result.

Diagnostics and Pockets

• There is
• Colour changes a rolled edge
• Enlarged and edematous. Bleeding and mobile tooth.

Pockets with Periodontal

Are objective. Radiographic test don't do enough testing

• Radiographic test show lost but not pocket
• Transgingival is a greater diagnostic for bones
• Use radiography to help assist. If in individual it will difficult to manage

• Active no probe minimum fluid (inactive)
• Greater fluids and active and exudate
• Attachment level can be lost ###Bacterial Sulcus +Mostly Coccus cells The pocket has more Spirochetes
• Alveolar must be tested with clinical and radiograph

Diagnostics of Furcation, Migration and sensitivity testing

• Height contours that are covered are usually helped with probing
• The root helps diagnose the bone through horizontal concave Transgingival under the bone for diagnostic The pocket formation destroys it, but is intact. Pulsate Exudates may also be a factor, but there's symptoms A Chronic is often open.
• However dull pain etc are symptoms

Abscess and Gingival Diagnostics

Location and History can cause gingival, may cause inflammatory response.

Diagnostics for Periapical or Periontal

Apical are most likely causes Extends to apex and causes pulpa,may suggest a periapical. If apex isnt able to be tested directly gingival is.

• Periapical can occur with no radiographics Cause symptoms for teeth that are not contributing, but radiographics help with it
• NANA
• WALAY The teeth are examines for restorative defects, wasting and proximal relationsipop. The shape, position and and stabilisation are also factor

Diseases of Teeth , Erosins

Smooth cause, the forms may result in a abfraction for the forms of wasting which are more angular Attrition - contact opposing each other

• Function will factor in the long wear.
• Atrrition that angles will increase periodontitis Ocullusal is flexure Micro fracture cause by abfration weakens the neck of tooth and causes more los
• Root surfaces exposed by receccesion are hypersesitive to temperature and exploration.
• They are sensitive by air blasts

###Contact Related

• Ischemic areas = IMPACTION
• Should be measured to maintain good contact The teeh that superrupte, distal can cause problems.

###Tooth, Mobility Related Greaters in morning, decreases through it

• the socket can move teeth as limited
• Single or multiple factors Occurs primary as horizontal
• mobility and the socket stages the gums and the force.
• Inflammation from periodontal to the ligamnets.
• Pregnancy increases factor

###Mobility causes cont

• the area is often a sign of localised periodsits, but may need to be tapped during persuccssion to diagnose This results in extraction. Effects by force - The the gums might need impingement. Tooth is position lingual and radiographics are needed Chart more films.

Periodontal diagnosis involves identifying the disease, its severity, and causes, following case history analysis and clinical evaluation. Focus on the patient, not just the disease, using systematic diagnostic procedures. Health history, gathered via questionnaires or interviews, is crucial for understanding systemic influences.