#2 Diagnosis Dr.Omer.pdf

Tishk University Faculty of Dentistry Periodontology Department Diagnosis of Periodontal Diseases Dr.Omer Naghshbandini DDS, MS, Phd  Special Thanks Whoever taught me a word made me his servant. Dr.raul Caffesse Dr. Jim Simon Definition Periodontal Diagnosis: Defin...

Tishk University Faculty of Dentistry Periodontology Department Diagnosis of Periodontal Diseases Dr.Omer Naghshbandini DDS, MS, Phd  Special Thanks Whoever taught me a word made me his servant. Dr.raul Caffesse Dr. Jim Simon Definition Periodontal Diagnosis: Defined as, identifying disease from an evaluation of the history, signs and symptoms, laboratory tests and procedures. Proper periodontal diagnosis is essential for successful treatment  Principles Of Diagnosis Sensitivity: refers to the ability of a test or observation to detect the disease whenever it is present. Healthy Diseased tissue  Principles Of Diagnosis Specificity: refers to the ability of a test or observation to clearly differentiate one disease from another. For example: differentiate gingival abscess from periapical abscess.  Principles Of Diagnosis Predictive value: refers to the probability of the test results. Early Periodontal disease Advanced Periodontal disease  Key Stages of Periodontal Diagnosis I. History recording II. Examination Should be followed for III.Investigation successful treatment IV.Diagnosis V. Treatment plan  History recording 1. Complains of / reason for attendance 2. History of presenting illness 3. Past dental history 4. Past medical history 5. Family history 6. Habits 7. Oral hygiene measures  Complains of / reason for attendance The most important point Either it’s: 1. Routine check 2. Referral to a specialist History of presenting illness Nature Onset Duration Severity of presenting complaint Past dental history Regular/irregular dental visit History of previous dental treatment Any problems related to post treatment Had preventive advise Past medical history Detailed medical history Family history Related oral disease Early loss of teeth  Habits Smoking Pan chewing Mouth breathing Tongue thrusting Clenching bruxism Oral hygiene measures Method of brushing Use of interdental aids Mouthwashes Examination: I. Extraoral examination TMJ Lymph node IExtraoral examination Lip competence  Examination: II. Intraoral examination Soft tissue examination: 1. Buccal and labial mucosa 2. Palate, floor of the mouth 3. Vestibule and tongue 4. Gingival features including color, contour, consistency, surface texture and bleeding on probing. 5. Periodontal features including pockets, mucogingival problems. Soft tissue examination: labial mucosa Buccal mucosa Soft tissue examination: Palate floor of the mouth Soft tissue examination: Buccal Vestibule Labial Vestibule  Soft tissue examination: Ventral surface of Side of tongue Dorsal surface of tongue tongue Soft tissue examination: Gingiva Soft tissue examination: Gingival features: Color Coral pink Redness Discoloration of gingiva Soft tissue examination: Gingival features: contour Knife edge Round edge Soft tissue examination: Gingival features: consistency Firm Edematous Soft tissue examination: Gingival features: surface texture Stippled ( orange peel) Loss of stipple Soft tissue examination: Gingival features: bleeding on probing Soft tissue examination: Periodontal features: pockets Soft tissue examination: Periodontal features: mucogingival problems.  Gingiva Gingival inflammation can cause two basic types of tissue response: ▫ 1. edematous ▫ 2. fibrotic. Edematous tissue response is characterized by: smooth, glossy, soft, red gingiva Fibrotic tissue response is characterized by: ▫ Some of the characteristics of normality persist ▫ The gingiva is more firm, stippled, and opaque ▫ It is usually thicker and its margin appears rounded Periodontal Examination Pocket  Pocket Probing The depth of penetration of a probe in a pocket depends on factors: Size of the probe Force with which it is introduced Direction of penetration Resistance of the tissues Convexity of the crown  periodontal pocket The periodontal pocket is defined as a pathologically deepened gingival sulcus, and it is one of the most important clinical features of the periodontal disease.  Classification Deepening of gingival sulcus may occur by: 1. Coronal movement of gingival margin 2. Apical displacement of the gingival attachment 3. A combination the two process  Classification Pockets can be classified as follows : 1. Gingival Pocket (Pseudopocket): Formed by gingival enlargement without destruction of the underlying tissues. The sulcus is deepened because of the increased bulk of the gingiva. 2. Periodontal Pockets: It occurs with destruction of supporting periodontal tissues.  Classification Periodontal Pockets Two types of periodontal pockets exist : I. Suprabony (Supracrestal or Supraalveolar): In this, bottom of the pocket is coronal to the underlying alveolar bone. II. Intrabony (Infrabony, Subcrestal or intraalveolar): In this, bottom of the pocket is apical to the level of the adjacent alveolar bone and the lateral pocket wall lies between the tooth surface & alveolar bone.  Classification Periodontal Pockets  Classification Periodontal Pockets Periodontal pockets can also be classified: A. According to involved tooth surface B. According to the nature of the soft tissue wall of the pocket C. According to disease activity  Classification Periodontal Pockets [A] According to involved tooth surface 1. Simple 2. Compound 3. Complex or Spiral – originating on one surface and twisting around the tooth to involve one or more additional surfaces ( most commonly found in furcation area)  Classification Periodontal Pockets [B] According to the soft tissue wall of the pocket: (1) Edematous Pocket. (2) Fibrotic Pocket. [C] According to disease activity: (1) Active Pocket. (2) Inactive Pocket.  Periodontal pockets Examination for periodontal pockets must include : presence and distribution on each tooth surface pocket depth level of attachment on the root type of pocket (suprabony or intrabony)  periodontal pockets Detection The only accurate method of detecting and measuring periodontal pockets is careful exploration with a periodontal probe Pockets are not detected by radiographic examination The periodontal pocket is a soft tissue change Radiographs indicate areas of bone loss where pockets may be suspected but important to understand: 1) they do not show pocket presence or depth 2)They show no difference before or after pocket elimination unless bone has been modified  Pocket Probing The two different pocket depths are: A) Biologic or histologic pocket depth B) Probing or clinical pocket depth Biologic depth is the distance between the gingival margin and the base of the pocket Probing depth is the distance to which a probe penetrates into the pocket  Clinical Attachment Level (CAL) versus Pocket Depth(PD) Pocket depth is the distance between the base of the pocket and the gingival margin It may change from time to time even in untreated periodontal disease owing to changes in the position of the gingival margin so it may be unrelated to the existing attachment of the tooth. The Clinical Attachment Level ( CAL) is the distance between cementoenamel junction and the base of the pocket Changes in the CAL can be due only to gain or loss of attachment and is a better indication for the degree of periodontal destruction or regeneration  Clinical Attachment Levels (CAL) The assessment of clinical attachment levels (CAL) provides information relating to the gain or loss of connective tissue attachment to the root surface It is the most practical method of determining that the disease is progressive (active) when a significant loss of attachment has occurred over time.  Bleeding on Probing the insertion of a probe to the bottom of the pocket elicits bleeding if the gingiva is inflamed and the pocket epithelium is atrophic or ulcerated Non inflamed sites rarely bleed. In most cases, bleeding on probing is an earlier sign of inflammation than gingival color changes. Sometimes color changes are found with no bleeding on probing.  Probing around implants Probing around them is part of examination and diagnosis. To prevent scratching of the implant surface, plastic periodontal probes should be used instead of the usual steel probes  Periodontal probes Periodontal probes are used to: locate, measure, and mark pockets Determine pockets configuration and their course on individual tooth surfaces.  Hard tissue examination Missing, carious tooth Restoration, impaction Proximal contact form Furcation involvement grades I, II, III and IV Mobility grades I, II, III Pathological migration Wasting disease Pulpo-periodontal problems Occlusal analysis Trauma from occlusion (Fremitus test)  Furcation involvement grades I, II, III and IV Grade I: the concavity just above the furcation entrance—on the root trunk can be felt with the probe tip; however, the furcation probe cannot enter the furcation area. Grade II The probe is able to partially enter the furcation—extending approximately one third of the width of the tooth—but it is not able to pass completely through the furcation Grade III In mandibular molars, the probe passes completely through the furcation between the mesial and distal roots. In maxillary molars, the probe passes between the mesiobuccal and distobuccal roots and touches the palatal root. Grade IV Same as a grade III furcation involvement except that the entrance to the furcation is visible clinically owing to tissue recession. Mobility grades I, II, III Pulpo-periodontal problems  Pathological migration Drifting of teeth into the spaces created by unreplaced missing teeth often occurs. Wasting disease Any gradual loss of tooth substance characterized by formation of polished surface, without regard to the possible mechanism of this loss. 1. Abrasion 2. Attrition 3. Erosion 4. Abfrcation Abrasion Attrition Abfraction Erosion Wasting disease  Investigation Radiographic investigation 1. Intraoral periapical radiograph 2. OPG Hematological investigation 1. Clotting time, bleeding time 2. RBC, WBC count, Hb% 3. Blood sugar analysis Biopsy Bacterial smear  Radiographic investigation Checking pattern of bone loss (Horizontal or vertical bone loss). Diagnosis Less than More than 30% 30% Gingivitis periodontitis Localized Generalized Gingivitis Plaque induced Necrotizing ulcerative Associated with systemic factors  Gingivitis Clinical features Based on course and duration Acute gingivitis: Sudden onset, Short duration, Painful Recurrent gingivitis : Reappears after treatment. Chronic gingivitis : Slow onset, long duration, Painless Based on distribution Localized gingivitis: Confined to single tooth or group of teeth Generalized gingivitis: Gingivitis involves entire mouth. Periodontists Chronic adult Aggressive Refractory/recurrent Treatment plan Emergency phase 1. Dental or periapical abscess 2. Periodontal abscess 3. Others, like splinting 4. Extraction Phase I therapy: Etiotrophic phase Removal of calculus and root planning Correction of restoration and prosthetic factors Temporary and final restorations Antimicrobial therapy, occlusal therapy, minor orthodontic movements, provisional splinting and prosthesis. Phase II therapy: Surgical phase Endodontic therapy Periodontal therapy 1. Pockets (Gingival, periodontal) 2. Gingival recession 3. Furcation involvement 4. others Implant therapy Phase III therapy: Restorative phase Final restoration Fixed and/or removable prosthodontics Phase IV therapy: Maintenance phase Periodic rechecking for: Plaque and calculus Gingival condition (pockets, inflammation) Occlusion, tooth mobility Other pathologic changes