Clinical Periodontal Assessment Textbook

Chapter 19 Clinical Periodontal Assessment Clinical Periodontal Assessment Clinical periodontal assessment is a fact-gathering process designed to provide a comprehensive picture of the patient’s periodontal health status. Clinical Periodontal Assessment (cont.) A clinical periodontal ass...

Chapter 19 Clinical Periodontal Assessment Clinical Periodontal Assessment Clinical periodontal assessment is a fact-gathering process designed to provide a comprehensive picture of the patient’s periodontal health status. Clinical Periodontal Assessment (cont.) A clinical periodontal assessment is one of the most important functions performed by the clinician. The information gathered during this assessment forms the basis of the patient: – Periodontal diagnosis – Individualized treatment plan Objectives of the Assessment Procedure Detect clinical signs of inflammation in the periodontium Identify existing damage caused by disease or trauma Provide data to assign periodontal diagnosis Document features of the periodontium for long-term monitoring of periodontal disease activity Standard of Care Dentists and dental hygienists have a legal responsibility to complete an accurate and thorough periodontal assessment on every patient. Documentation of Findings The periodontal assessment is not complete until all information gathered has been accurately recorded in the patient chart. Documentation measures treatment outcomes. Documentation monitors periodontal health status over time. Documentation of Findings (cont.) Findings documented during initial clinical periodontal assessment serve as baseline data. Baseline data is used in the long-term monitoring of the patient’s periodontal health status (e.g., are pocket depths remaining the same? Getting deeper?)  Two Types of Periodontal Assessment Periodontal Screening Examination--- quick process to determine if a more comprehensive assessment is needed Comprehensive Periodontal Assessment--- intensive and in-depth information-gathering process Periodontal Assessment Components Gingival inflammation Level of free gingival margin Recession of the gingiva Level of mucogingival junction Probing depth measurements Bleeding on probing Periodontal Assessment Components (cont.) Presence of exudate Tooth mobility Furcation involvement Presence of calculus deposits on the teeth Presence of dental plaque biofilm Figure 19-1: Landmarks of the Gingival Tissues. Important gingival landmarks include the gingival margin, the interdental papilla, free gingiva, attached gingiva, and mucogingival junction Used with permission from Wilkins EM. Clinical Practice of the Dental Hygienist. 12th ed. Philadelphia, PA: Wolters Kluwer; 2017  The Gingiva Evaluate the health of the gingiva: – Tissue color – Contour – Consistency – Texture  Evaluate Gingival Inflammation Assess overt clinical signs of gingival inflammation – Erythema – Edema – Gingival color – Contour Level of the Free Gingival Margin Possibility of several different relationships of free gingival margin (FGM) to cementoenamel junction (CEJ) – FGM slightly coronal to the CEJ = normal position – FGM significantly coronal to the CEJ = gingival enlargement – FGM apical to the CEJ = recession of gingival margin Figure 19 2: Level of the Free Gingival Margin. The photo on the left is an example of the gingival margin in health—slightly coronal to the CEJ. The center photo shows swollen gingiva where the gingival margin is coronal to the CEJ. In the photograph on the right, the gingival margin on the canine teeth is apical to the CEJ (recession of the gingival margin Figure 19-2: Level of the Free Gingival Margin. The photo on the left is an example of the gingival margin in health—slightly coronal to the CEJ. The center photo shows swollen gingiva where the gingival margin is coronal to the CEJ. In the photograph on the right, the gingival margin on the canine teeth is apical to the CEJ (recession of the gingival margin Figure 19-2: Level of the Free Gingival Margin. The photo on the left is an example of the gingival margin in health—slightly coronal to the CEJ. The center photo shows swollen gingiva where the gingival margin is coronal to the CEJ. In the photograph on the right, the gingival margin on the canine teeth is apical to the CEJ (recession of the gingival margin  Gingival Recession Refers to displacement of the gingival soft tissue margin apical to the CEJ Results in root exposure Common clinical condition Presence increases with age Can occur in patients with good oral hygiene  Miller Classification Figure 19-3: Miller Class I Defect. In a Miller Class I gingival defect, the recession is isolated to the facial surface and the interdental papillae fill the adjacent interdental spaces. Class I recession does not extend to the mucogingival line  Figure 19-3: Miller Class II Defect. In a Miller Class II gingival defect, the recession is isolated to the facial surface and the papillae remain intact and fill the interdental spaces. Class II recession does extend to or beyond the mucogingival line into the mucosa Figure 19-3: Miller Class III Defect. In a Miller Class III gingival defect, the recession is quite broad with the interdental papillae missing due to damage from disease. The Class III defect extends to or beyond the mucogingival line into the mucosa  Figure 19-3: Miller Class IV Defect. In a Miller Class IV gingival defect, the recession extends to or beyond the mucogingival junction with severe loss of interproximal alveolar bone resulting in open interdental areas. Level of Mucogingival Junction Junction between the keratinized gingiva and the nonkeratinized mucosa Usually easy to detect because of color definition – Keratinized is pale pink – Nonkeratinized is thinner and more vascular Figure 19-4: Mucogingival Junction. The mucogingival junction represents the junction between the keratinized gingiva and the nonkeratinized mucosa and is usually readily visible. Probing Depths Measurement from the free gingival margin to the base of the pocket Recorded to the nearest millimeter Half measurements are rounded up to the next whole number Depths are recorded for six sites on each tooth Bleeding on Probing Represents bleeding from ulcerated soft tissue wall of the periodontal pocket Can occur immediately when the site is probed Can be delayed Excessive force could also cause bleeding Figure 19-5: Bleeding Site. Bleeding from the soft tissue wall is a sign of disease. This bleeding was evident upon gentle probing Courtesy of Dr. Richard Foster, Guilford Technical Community College, Jamestown, NC Presence of Exudate Exudate is also called suppuration or pus Represents dead white blood cells Can only occur in infection Pale yellow material that oozes from the orifice of a pocket Easiest to detect by tissue manipulation  Figure 19-6: Using Finger Pressure to Detect Exudate. Exudate can be detected in a periodontal pocket by placing an index finger on the soft tissue in the area of the pocket and exerting light pressure. This light pressure can force the exudate out of the pocket, making it readily visible to the clinician. Figure 19-7: Pressure with the clinician’s finger on the gingiva reveals exudate from the gingival tissue adjacent to the central incisor Courtesy of Dr. Richard Foster, Guilford Technical Community\ College, Jamestown, NC.  Figure 19.7B: Exudate also is visible during probing Courtesy of Dr. Richard Foster, Guilford Technical Community College, Jamestown, NC. Figure 19.7C: Radiograph of the same incisor shown in Figure 20-3A and 20-3B. Courtesy of Dr. Richard Foster, Guilford Technical Community College, Jamestown, NC. Tooth Mobility Horizontal tooth mobility is the movement of a tooth in the facial to lingual direction. – Adjacent tooth is observed as a point of reference. Vertical tooth mobility is the movement of a tooth up and down in the socket.  Figure 19-8: Determining Horizontal Tooth Mobility. To determine buccolingual mobility, the blunt ends of two instrument handles are applied to the tooth to see if it can be displaced buccolingually. Light, alternating force is applied with the instrument handles to detect movement relative to the adjacent teeth. sed by permission from Scheid RC, Woelfel JB. Woelfel’s Dental Anatomy: Its Relevance to Dentistry. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007 Figure 19-1: SCALE FOR RATING VISIBLE TOOTH MOBILITY Figure 19-9A: The patient came to the dental office complaining of a loose tooth. Note the supraeruption of the maxillary left central incisor Courtesy of Dr. Don Rolfs, Wenatchee, WA.  Figure 19-9B: The patient then demonstrated how he could push this tooth upward by applying pressure with his index finger against the incisal edge. This central incisor has vertical mobility. Courtesy of Dr. Don Rolfs, Wenatchee, WA.  Fremitus A palpable or visible movement of a tooth when in function Can be assessed by gently placing a gloved index finger against the facial aspect of the tooth as the patient either taps the teeth together or simulates chewing movements Furcation Involvement Occurs on multirooted teeth when periodontal infection invades the bone around the roots Involvement frequently signals need for periodontal surgery Detected with blunt-ended, curved furcation probes  Figure 19-10: The photograph on the left shows a furcation involvement as viewed from the facial aspect of a mandibular first molar. On the right, a radiograph of the same molar tooth shows bone loss between the roots of this molar.  Figure 19-10: The photograph on the left shows a furcation involvement as viewed from the facial aspect of a mandibular first molar. On the right, a radiograph of the same molar tooth shows bone loss between the roots of this molar. Figure 19-2: SCALE FOR RATING FURCATION INVOLVEMENT Presence of Calculus Deposits Local contributing factor that must be removed for successful treatment Located through – Direct visual examination – Visually when using air – Tactile examination Presence of Plaque Biofilm Contain live periodontal pathogens Can be identified with disclosing solution Plaque scores are excellent motivating tools What tool do we use? Presence of Local Contributing Factors A thorough periodontal assessment includes identification of local contributing factors Can you name a few? Radiographic Evidence of Bone Loss Radiographic evidence of bone loss plays an important part of a clinical periodontal assessment. How do we evaluate?  Assessment Components Requiring Calculations Width of attached gingiva Mucogingival defects – Recession – Absence of keratinized tissue Clinical attachment level Attached Gingiva Calculation Figure 19-11A: The total width of the gingiva from the gingival margin to the mucogingival junction is 2 mm. Used by permission from Scheid RC, Woelfel JB. Woefel’s Dental Anatomy Its Relevance to Dentistry. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007  Attached Gingiva Calculation Figure 19-11B: The probing depth—from the gingival margin to the base of the pocket—is 1 mm. Thus, this site has 1 mm of attached gingiva Used by permission from Scheid RC, Woelfel JB. Woefel’s Dental Anatomy Its Relevance to Dentistry. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007 Attached Gingiva Calculation Figure 19-12: Calculating the Width of Attached Gingiva Attached Gingiva Calculation Figure 193-12: Calculating the Width of Attached Gingiva  Clinical Attachment Level Figure 19.-13A: Calculating Clinical Attachment Level when the Gingival Margin is slightly coronal to the Cementoenamel Junction. When the gingival margin is slightly coronal to the CEJ, no calculations are needed since the probing depth and the clinical attachment level are equal.  Clinical Attachment Level Figure 19-13B: Calculating Clinical Attachment Level when the Gingival Margin is significantly coronal to the Cementoenamel Junction. When the gingival margin is significantly coronal to the CEJ, the CAL is calculated by SUBTRACTING the gingival margin level from the probing depth.  Clinical Attachment Level Figure 19-13C: Calculating Clinical Attachment Level in the Presence of Gingival Recession. When recession is present, the CAL is calculated by ADDING the probing depth to the gingival margin level.