Periodontics Notes 2023/2024 PDF

Periodontics (OBCS 445) Academic Year 2023/ 2024 Course Director: Dr. Bushra Aljahdli Co-course Directors: Dr. Shatha Bamashmous done by t.rs El Yahya pea Anatomy of the Period...

Periodontics (OBCS 445) Academic Year 2023/ 2024 Course Director: Dr. Bushra Aljahdli Co-course Directors: Dr. Shatha Bamashmous done by t.rs El Yahya pea Anatomy of the Periodontium and Comprehensive Periodontal Examination Dr. Shatha Bamashmous BDS, MSD, Dip ABP, FRCD(C), PhD Assistant Professor and Consultant Department of Periodontology [email protected]  Lecture’s outline The Anatomy of the Periodontium Comprehensive Periodontal Examination  ILOs 1.Describe different parts of the periodontium Gingiva PDL Alveolar bone Cementum 2.Describe gingival criteria (color, consistency, texture, size and shape, suppuration) 3.Record plaque index and bleeding on probing (BOP) 4.Demonstrate calculus detection techniques using 11/12 explorer 5.Demonstrate accurate periodontal probing technique (PD) 6.Calculate clinical attachment loss (CAL) 7.Distinguish between significance of PD and CAL 8.Measure keratinized and attached gingiva 9.Locate the mucogingival junction (MGJ) 10.List the furcation grading according to Glickman’s classification 11.Detect furcation involvement on patients 12.List mobility grades according to Miller 13.Detect mobility clinically  Lecture’s outline The Anatomy of the Periodontium Comprehensive Periodontal Examination  Components of the periodontium What is periodontics or periodontology? the study of the tissue supporting the tooth  Components of the periodontium What is Periodontium? Gingiva soft tissue Periodontal Ligament Cementum hard tissue Alveolar Bone f Components of the periodontium Gingiva Cementum Periodontal Ligament Alveolar Bone Components of the periodontium- Gingiva Gingiva: Covers the alveolar bone and tooth root to a level just coronal to cementoenamel junctions Function: Physical barrier to the penetration by microbes and noxious agents into the deeper tissue  Components of the periodontium- Gingiva Important to know J Clinical features because the changes Microscopic features thathappens during disease on the clinicalfeat Correlation of Clinical andreflects Microscopic Features  Gingiva - Clinical features Marginal Gingival free gingi TParts: Marginal gingiva Attached Gingiva Attached gingiva Interdental Gingiva Alveolar mucosa  Gingiva - Clinical features Marginal Gingival Marginal Gingiva: The marginal, or unattached, gingiva is the terminal edge or border of the gingiva surrounding the teeth in collar- like fashion  Gingiva - Clinical features Gingival sulcus Marginal Gingival Marginal Gingiva: Forms the soft tissue wall of the gingival sulcus 1mm wide  Gingiva - Clinical features Marginal Gingiva: The most apical point of the marginal gingival scallop is called the gingival zenith Chu et al., Esthet Restor Dent 2009 R b Important for esthetic  Gingiva - Clinical features Gingival sulcus may be found and 1 Son Patients may not Marginal Gingival Free gingival Free gingival groove: grove Shallow linear depression that demarcates the marginal gingiva from Attached gingiva the adjacent attached gingiva 50 % of cases  Gingiva - Clinical features between the teeth and Gingival sulcus the gingiva Marginal Gingival f Gingival sulcus: Free gingival The space bounded by the free grove gingiva and the tooth V-shaped Probing depth of a clinically normal gingival sulcus 2 - 3 mm  Gingiva - Clinical features Gingival sulcus Marginal Gingival Free gingival Attached gingiva: grove Keratinized, firm, resilient, and tightly bound to the alveolar bone Attached gingiva  Gingiva - Clinical features Gingival sulcus Marginal Gingival Free gingival Attached gingiva: grove Keratinized, firm, resilient, and tightly bound to the alveolar bone Attached gingiva Extends to apically to alveolar mucosa attached gingiva and Alveolar mucosa nakginal gingiva are keratin  alveolal bone Is not keratin Gingiva - Clinical features Gingival sulcus Marginal Gingival Free gingival grove Mucogingival Junction (MGJ): Junction between keratinized attached gingiva and non Attached gingiva keratinized alveolar mucosa Mucogingival junction Alveolar mucosa  Gingiva - Clinical features Gingival sulcus Marginal Gingival The width of the attached gingiva: Free gingival Distance between the mucogingival grove junction and the projection on the external surface of the bottom of Attached gingiva the gingival sulcus or the periodontal pocket Mucogingival junction Alveolar mucosa  0 Gingiva - Clinical features The width of the attached gingiva: Gingival sulcus Distance between the mucogingival Marginal Gingival junction and the projection on the Free gingival grove external surface of the bottom of the gingival sulcus or the periodontal pocket Attached gingiva VS Mucogingival The width of the keratinized gingiva junction includes the marginal gingiva Alveolar mucosa  Gingiva - Clinical features i The width of the attached gingiva varies Widest in the anterior teeth Narrowest in premolars Increases with age and in supraerupted teeth a  Gingiva - Clinical features Interdental Gingiva: Occupies the gingival embrasure The interdental gingiva can be pyramidal, or a I “col” shape 1 In the Interior region Posterior region  Gingiva - Clinical features Interdental Gingiva: The shape depends: ✓ Presence or absence of a contact point ✓ Distance between the contact point and the osseous crest ✓ Presence or absence of recession  Gingiva - Clinical features Interdental Gingiva: Diastema—> no interdental papilla When no Contact  Components of the periodontium- Gingiva Clinical features Microscopic features Correlation of Clinical and Microscopic Features  Gingiva - Microscopic features Component: Epithelium: predominantly cellular Connective tissue: collagen fibers (about 60% by volume), fibroblasts (5%), vessels, nerves, and matrix (35%) nai ly of fibers  Gingiva - Microscopic features Gingival epithelium: Stratified squamous epithelium  Gingiva - Microscopic features Why Sulcular keratinize epithelium Gingival epithelium: Three different areas: q Junctional ✓ The oral or outer epithelium epithelium ✓ Sulcular epithelium ✓ junctional epithelium Oral epithelium  Gingiva - Microscopic features Sulcular Sulcular epithelium: epithelium Lines the gingival sulcus A thin , non-keratinized stratified squamous epithelium without rete pegs Extends from the coronal limit of the JE to the crest of gingival margin  Gingiva - Microscopic features Sulcular Junctional epithelium: epithelium Non-keratinized Junctional Tapers from its coronal end (10 to epithelium 29 cells) to (1 or 2 cells) at its apical termination. Attached to tooth by hemidismosomes I og is W  the Salculat Gingiva - Microscopic features Sulcular Oral epithelium: epithelium Covers the marginal gingiva and Junctional the surface of the attached gingiva epithelium Keratinized or parakeratinized Oral epithelium  Gingiva - Microscopic features Gingival fibers Three groups: Gingivodental Circular Transeptal  Components of the periodontium- Gingiva Clinical features Microscopic features Correlation of Clinical and Microscopic Features  Clinical features of the gingiva- Color Attached and marginal gingiva color is “coral pink ˮ The color depends upon: ✓the vascular supply ✓the thickness/degree of keratinization of the epithelium ✓the presence of pigment containing cell  Clinical features of the gingiva- Color The alveolar mucosa is red, smooth, and shiny The epithelium of the alveolar mucosa is thinner and non-keratinized, and no rete pegs Connective tissue is loosely arranged, and the blood vessels are more numerous.  Clinical features of the gingiva- Size The size of the gingiva corresponds with the sum total of the bulk of cellular and intercellular elements and their vascular supply Size alteration is a feature of gingival disease  Clinical features of the gingiva- Contour The marginal gingiva follows a scalloped outline on the facial and lingual surfaces Varies considerably and depends on the: ✓ Shape of the teeth and their alignment in the arch ✓ Location and size of the area of proximal contact ✓ Dimensions of the facial and lingual gingival embrasures  Clinical features of the gingiva- Shape Shape of the interdental gingiva is governed by: ✓ contour of the proximal tooth surfaces ✓ location and shape of gingival embrasures The height of the interdental gingiva varies with the location of the proximal contact ✓ anterior region, the interdental papilla is pyramidal ✓ Molar region, the papilla is more flattened  f Clinical features of the gingiva- Consistency The gingiva is firm and resilient Alteration in consistency in disease  Clinical features of the gingiva- Position The the level at which the gingival margin is attached to the tooth T The apical migration of the gingiva is called gingival recession  Lecture’s outline The Anatomy of the Periodontium Comprehensive Periodontal Examination  ILOs 1.Describe different parts of the periodontium Gingiva PDL Alveolar bone Cementum 2.Describe gingival criteria (color, consistency, texture, size and shape, suppuration) 3.Record plaque index and bleeding on probing (BOP) 4.Demonstrate calculus detection techniques using 11/12 explorer 5.Demonstrate accurate periodontal probing technique (PD) 6.Calculate clinical attachment loss (CAL) 7.Distinguish between significance of PD and CAL 8.Measure keratinized and attached gingiva 9.Locate the mucogingival junction (MGJ) 10.List the furcation grading according to Glickman’s classification 11.Detect furcation involvement on patients 12.List mobility grades according to Miller 13.Detect mobility clinically  Overall Appraisal of the Patient Health history Dental history  Overall Appraisal of the Patient Yea I Health history ✓ Physical exams (date, frequency) ✓ History of hospitalizations and operations ✓ Medical problems ✓ Abnormal bleeding tendencies ✓ List of medications (anticoagulants, bisphosphonates) ✓ Females (pregnancies, puberty, menopause) ✓ Allergy history ✓ Family history ✓ Tobacco use  Yeah Overall Appraisal of the Patient Dental history ✓ Chief complaint ✓ Frequency of dental visit ✓ Oral hygiene regimen ✓ Pain ✓ Bleeding ✓ Mobility ✓ Dental habits ✓ History of periodontal disease ✓ Implants ✓ Removable prosthesis ✓ Orthodontic treatment  Clinical Examination Examination of Extraoral Structures Examination of the Oral Cavity Examination of the Periodontium  Comprehensive Periodontal Examination Assessment of the gingiva: (Color, size, shape, consistency, surface texture) Assessment of the periodontal breakdown: Probing depth Clinical attachment loss (CAL) Furcation involvement Bleeding on probing Plaque score Mucogingival defects: Gingival recession Width of keratinized gingiva Width of attached gingiva. Evaluation of teeth and occlusion: Teeth mobility Teeth migration Trauma from occlusion Fremitus Para functional habits Wasting disease of the teeth (abrasion, erosion, abfraction) Radiographic examination Assessment of the gingiva describe be sins criteria Fitst step  Assessment of the gingiva Color Shape Size Consistency Surface texture Exudate Bleeding on probing  Assessment of the gingiva Remember to dry the gingiva with gauze  Assessment of the gingiva- Color Possible changes in Criteria How to describe Normal findings disease Distribution: localized or Color generalized Coral pink or salmon erythematous (redness) Position: marginal, pink or cyanotic (bluish red) papillary, or diffuse Assessment of the gingiva- Color  Assessment of the gingiva- Color Generalized coral pink A Generalized marginal redness when Include all the area we said sing1 if it 1  P GappI Assessment of the gingiva- Color  Assessment of the gingiva- Color Generalized coral pink with physiologic pigmenation  Assessment of the gingiva- Contour Possible changes in Criteria How to describe Normal findings disease Contour Contour of the gingiva Scalloped Flat Assessment of the gingiva- Contour  Assessment of the gingiva- Contour Flat Scalloped  Assessment of the gingiva- Shape Possible changes in Criteria How to describe Normal findings disease Knife edge Rolled Gingival margin Shape Pointed or pyramidal, and Interdental papilla fill the interproximal Round, blunt, or bulbous space  Assessment of the gingiva- Shape How to test? Visual examination Side of the probe Gingival margin  Assessment of the gingiva- Shape Interdental papilla Assessment of the gingiva- Shape  Assessment of the gingiva- Shape Gingival margin: knife edge Interdental papilla: pointed or pyramidal  Assessment of the gingiva- Shape Gingival margin: knife edge Gingival margin: rolled Interdental papilla: pointed or pyramidal Interdental papilla: bulbous/round  Assessment of the gingiva- Consistency Possible changes in Criteria How to describe Normal findings disease Consistency Firm and resilient Edematous or fibrotic b  Assessment of the gingiva- Consistency How to test? Side of the probe Usual It In the buccal side oil Mainly at the gingival margin and interdental papilla  Assessment of the gingiva- Surface texture Possible changes in Criteria How to describe Normal findings disease Surface Matte, stippled Smooth, shiny texture Assessment of the gingiva- Surface texture  Assessment of the gingiva- Surface texture Matte, stippled Smooth, shiny  Assessment of the gingiva- Exudate Range from clear serous liquid to highly viscous pus (purulent exudate). Purulent exudate: dead neutrophils, serum protein, bacteria.  Assessment of the gingiva- BOP Probe around each tooth to the bottom of the sulcus, wait 30-60 seconds and record presence or absence of bleeding. Record 6 sites around each tooth: Disto-buccal, buccal, mesio-buccal, Mesio-lingual/ palatal, Lingual/palatal, Disto-lingual/palatal.  Assessment of the gingiva- BOP False bleeding on probing: Multiple insertion of the probe at the same site High probing force  Assessment of the gingiva- BOP Probing force: 25 gram = 0.25 N  Assessment of the gingiva- BOP Bleeding index = No. of bleeding sites X 100 Total number of sites  Assessment of the gingiva- BOP C Bleeding index = No. of bleeding sites X 100 Total number of sites Total number of sites= total no. of teeth X 6  Assessment of oral hygiene- Plaque index Use the disclosing tablet (methylene red) Record the stained plaque area (Cervical areas only) Record 4 sites around each tooth: Mesial, distal, buccal, lingual/ palatal is b It I blood Index Igg Assessment of oral hygiene- Plaque index  Assessment of oral hygiene- Plaque index Plaque index = No. of stained surfaces X 100 Total number of surfaces b  Assessment of the gingiva- Plaque index Plaque index = No. of stained surfaces X 100 Total number of surfaces Total number of surfaces= total no. of teeth X 4 Calculus detection  Calculus detection 11/ 12 explorer OK by  Indiog apb Calculus detection Lower shank parallel to the long axis of tooth Working tip is slightly tilted toward the tooth Zigzag motion (apico-coronal)  Calculus detection Q4Q3 Q3Q3 Calculus detection form  Assessment of the periodontal breakdown Probing depth (PD) Clinical attachment level (CAL)  Assessment of the periodontal breakdown- Probing depth What is probing depth? The distance from the gingival margin to the bottom of the sulcus/ periodontal pocket Assessment of the periodontal breakdown- Probing depth There are two different pocket depths: Shallower Biologic depth: from the gingival margin to the the coronal end of the Junctional epithelium. This can be measured only in histologic sections Clinical probing depth: distance to which a probe penetrates into the pocket Assessment of the periodontal breakdown- Probing depth Which one is shallower? Assessment of the periodontal breakdown- Probing depth Which one is shallower? The biologic/histologic pocket depth is always shallower than the clinical/probing pocket depth.  Assessment of the periodontal breakdown- Probing depth Why are they different? Probe penetration depends Force of probing Degree of tissue inflammation Shape and size of the probe tip Direction of penetration Convexity of the crown A normal sulcus B Periodontal pocket  Assessment of the periodontal breakdown- Probing depth How would you measure the clinical sulcus/pocket depth? Periodontal probe A  Assessment of the periodontal breakdown- Probing depth Periodontal probe: Measuring periodontal pocket depths Measure clinical attachment loss Measure extent of recession of the gingival margin Measure the width of the attached gingiva Measure the size of intraoral lesions Assess bleeding on probing Determine mucogingival relationships Monitoring the longitudinal response of the periodontium to treatment  Assessment of the periodontal breakdown- Probing depth A: Marquis color-coded probe. Calibrations are in 3-mm sections B: University of North Carolina 15 probe, a 15-mm long probe marked at each millimeter and color coded at the 5th, 10th, and 15th millimeters C: University of Michigan “O” probe, with Williams markings (at 1, 2, 3, 5, 7, 8, 9, and 10 mm) D: Michigan “O” probe with markings at 3, 6, and 8 mm. E: World Health Organization probe, which has a 0.5-mm ball at the tip and markings at 3.5, 8.5, and 11.5 mm and color coding from 3.5 to 5.5 mm. Types of periodontal probes  Assessment of the periodontal breakdown- Probing depth Is I O The UNC-15 probe has millimeter markings at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15 mm. Colored bands between 4 and 5 mm, 9 and 10 mm, and 14 and 15 mm  Assessment of the periodontal breakdown- Probing depth Probing force: 25 gram = 0.25 N Difficult to reproduce the force, site of reading, and angulation of the probe 1 mm variation is acceptable  Assessment of the periodontal breakdown- Probing depth Probing technique (walking) E 1 mm interval The probe inserted into the Sulcus/ pocket and walked circumferentially around the tooth.  Assessment of the periodontal breakdown- Probing depth Probing technique (parallelism)  Assessment of the periodontal breakdown- Probing depth Probing technique (parallelism) The probe should be parallel to the long axis of the tooth (Exaggerated angulations —> high readings).  Assessment of the periodontal breakdown- Probing depth Probing technique (adaptation) I b l's So The probe should be adapted to the contour of the tooth The side of the probe’s tip should be in contact with the tooth surface  Assessment of the periodontal breakdown- Probing depth Probing technique (adaptation) Probe is not parallel to the root surface —> underestimation of the measurement  Assessment of the periodontal breakdown- Probing depth Probing technique (interproximal) Jk Walk the probe Reach the contact point Slightly tilt w  IT s Assessment of the periodontal breakdown- Probing depth Probing technique (interproximal) Walk the probe Reach the contact point Slightly tilt  Assessment of the periodontal breakdown- Probing depth Probing technique (interproximal) How much is the tilt? Posterior teeth —> wide contact area —> more tilt Anterior teeth —> narrow contact area— > less tilt  Assessment of the periodontal breakdown- Probing depth Probing technique (recording) What do you record in the patient chart? 1. Six Areas per Tooth. Probing depth measurements are recorded for six areas on each tooth: (1) distofacial, (2) facial, (3) mesiofacial, (4) distolingual, (5) lingual, and (6) mesiolingual  Assessment of the periodontal breakdown- Probing depth Probing technique (recording) What do you record in the patient chart? 2. One Reading per Area. the deepest reading obtained in that area is recorded I always  Assessment of the periodontal breakdown- Probing depth Probing technique (recording) What do you record in the patient chart? 3. Full Millimeter Measurements. Round up measurements to the next higher whole number  Assessment of the periodontal breakdown- Probing depth Probing technique (recording) Assessment of the periodontal breakdown- Clinical attachment loss The distance between the base of the pocket and a fixed point on the crown, the cementoenamel junction (CEJ) The extent of periodontal support that has been destroyed around a tooth Assessment of the periodontal breakdown- Clinical attachment loss How to calculate CAL? 1- locate the cementoenamel junction (CEJ) 2- Mesure the distance from gingival margin (GM) to CEJ 3- CAL= PD + (GM to CEJ) Assessment of the periodontal breakdown- Clinical attachment loss Relationship of GM to CEJ 3 possible scenarios: Gingival margin is apical to the CEJ Gingival margin is coronal to the CEJ Gingival margin is at the CEJ Assessment of the periodontal breakdown- Clinical attachment loss How to calculate CAL? If the GM is apical to CEJ: CAL= PD + (GM to CEJ) to Example: CAL = 4 mm + 2 mm = 6mm GM to CEJ = 2 mm PD = 4 mm Assessment of the periodontal breakdown- Clinical attachment loss How to calculate CAL? If the GM is coronal to CEJ: CAL= PD - (GM to CEJ) Example: CAL = 9 mm - 3 mm = 6 mm. ay GM to CEJ = 3 mm PD = 9 mm  Assessment of the periodontal breakdown- Clinical attachment loss How to calculate CAL? If the GM is at the level of the CEJ: CAL = PD Example: CAL = 6 mm GM to CEJ = 0 mm PD = 6 mm  Assessment of furcation r r Furcation is the place on a multirooted tooth where the root r trunk divides into separate roots.  Assessment of furcation 0 Furcation is the place on a Furcation involvement means multirooted tooth where the root bone loss reached the level of trunk divides into separate roots. the furcation  Assessment of furcation 9 SEE A furcation probe is a type of periodontal probe used to a evaluate the bone support in the furcation areas T Nabers probe: 1st mark 3-6 mm, 2nd mark 9-12 mm  Assessment of furcation Maxillary molars Trifurcated. 2 buccal roots (mesio-buccal and disto-buccal) and one palatal root, Buccal, mesial, and distal furcations. Mesial furcation is located more toward the palatal surface, accessible from the palatal aspect. The distal furcation is located more toward the center of the tooth, accessible from either buccal or palatal aspects (still palatal access is easier) Maxillary prmolars: Bifurcated Buccal and palatal roots  Assessment of furcation Maxillary premolars Mesial furcation: accessible from the palatal aspect Distal furcation: accessible from palatal aspect  Assessment of furcation Maxillary molars Buccal furcation: accessed from buccal  Assessment of furcation Maxillary molars Buccal furcation: accessed from buccal Mesial furcation: accessible from the palatal aspect.  Assessment of furcation Maxillary molars Buccal furcation: accessed from buccal Mesial furcation: accessible from the palatal aspect. Distal furcation: Accessible from either buccal or palatal aspects (still palatal access is easier)  Assessment of furcation Mandibular molars Bifurcated Mesial and distal roots Buccal and lingual furcations are accessible from the buccal and lingual aspects.  Assessment of furcation Mandibular molars Buccal furcation: accessed from buccal Lingual furcation: accessed from lingual Glickman classification Assessment of furcation Grade and symbol Bone loss at the Clinical Radiograph furcation I incipient Catch of nabers Not detected probe II Partial Partial penetration Furcation arrow III complete Through and through Radiolucency at furcation IV complete Visible by eye Radiolucency at furcation Glickman classification Assessment of furcation  Mucogingival deformities What is the mucogingival junction? Junction between attatched _________ and ___________ Alveolar singive mica  Mucogingival deformities What is the mucogingival junction? Junction between attached gingiva and alveolar mucosa  Mucogingival deformities What is the width of keratinized gingiva? The distance from _________ to ________.  Mucogingival deformities What is the width of keratinized gingiva (KG)? The distance from mucogingvial junction to the gingival margin  Mucogingival deformities What is the width of attached gingiva? Distance between _____and _____  Mucogingival deformities What is the width of attached gingiva? Distance between the mucogingival junction and the projection on the external surface of the bottom of the gingival sulcus or the periodontal pocket  Mucogingival deformities How to locate the mucogingoval junction? Very clear by color difference  Mucogingival deformities How to locate the mucogingoval junction? Very clear by color difference Rolling test  Mucogingival deformities How to locate the mucogingoval junction? Very clear by color difference Rolling test Blanching test H e EH E T  Mucogingival deformities How to measure attached gingiva? - Measure the total width of the keratinized gingiva (from GM to MGJ) - Measure the probing depth (from GM to base of the pocket) - Subtract PD from GM to MGJ measurement Attached gingiva = (GM to MGJ) – Probing depth C: gingival margin A: bo/om of the sulcus or pocket B: mucogingival junc;on Shaded area: amount of a/ached gingiva Mucogingival deformities Mucogingival deformities Mucogingival deformities  Mucogingival deformities Gingival or soft tissue recession: Yead In general Cairo classification it will be explain later Recession Type 1 (RT1): Gingival recession with no loss of interproximal attachment. Interproximal CEJ is clinically not detectable at both mesial and distal aspects of the tooth Recession Type 2 (RT2): Gingival recession associated with loss of interproximal attachment. The amount of interproximal attachment loss (measured from the interproximal CEJ to the depth of the interproximal sulcus/pocket) is less than or equal to the buccal attachment loss (measured from the buccal CEJ to the apical end of the buccal sulcus/pocket) Recession Type 3 (RT3): Gingival recession associated with loss of interproximal attachment. The amount of interproximal attachment loss (measured from the interproximal CEJ to the apical end of the sulcus/pocket) is greater than the buccal attachment loss (measured from the buccal CEJ to the apical end of the buccal sulcus/ pocket) Francesco Cairo et al (2011)  Mucogingival deformities Gingival or soft tissue recession: Cairo classification (1) Recession Type 1 (RT1). Francesco Cairo et al (2011)  Mucogingival deformities Gingival or soft tissue recession: Cairo classification (2) Recession Type 2 (RT2). Francesco Cairo et al (2011)  Mucogingival deformities Gingival or soft tissue recession: Cairo classification (3) Recession Type 3 (RT3). Francesco Cairo et al (2011) Evaluation of teeth and occlusion- Proximal contact, contour, margin of restorations How to record in the periodontal chart? Overhang restoration Open contact Food impaction  Evaluation of teeth and occlusion- Wasting disease of the teeth Erosion Abrasion Attrition Abfraction  Evaluation of teeth and occlusion- Para functional habits Para functional habits ? Bruxism Clenching What do you see clinically? Attrition Wear facets Evaluation of teeth and occlusion- Teeth migration How to record migration on the chart?  Evaluation of teeth and occlusion- Mobility Teeth mobility: Physiologic mobility Mobility beyond the physiologic range —> abnormal or pathologic Main etiologic factors of tooth mobility are periodontal inflammation, attachment loss, and occlusal trauma  Evaluation of teeth and occlusion- Mobility How to examine? Tooth held firmly between handle of 2 instruments and moved back and forth, also vertically With one metallic instrument and one finger  Evaluation of teeth and occlusion- Mobility Miller classification I: Tooth moves less than 1 mm in a bucco-lingual or mesio-distal direction. if II: Tooth moves 1 mm or more in a bucco-lingual or mesio-distal direction. III: Tooth moves 1 mm or more in both bucco-lingual or mesio-distal and vertical directions.  Evaluation of teeth and occlusion- Fremitus Definition: Fremitus is a vibratory movement of teeth during functional occlusal forces in centric or eccentric movement. Fremitus vs. mobility: Fremitus is tooth displacement by functional force Mobility is tooth displacement by force applied by the examiner.  Evaluation of teeth and occlusion- Fremitus Classification of fremitus Class I fremitus: Mild vibration detected. Class II fremitus: Easily palpable vibration but not visible. Class III fremitus: Movement is visible with the naked eye Radiographic examination  Radiographic examination Panormic radiographs in assessment of: Overall bone pattern Anatomical landmarks; maxillary sinus position, inferior alveolar canal, mental foramens, etc but not for periodontal assessment.  Radiographic examination Bitewing radiographs in assessment of: The alveolar crest height The relation of the CEJ to the alveolar crest. Local irritating factors (calculus, overhang restoration). Pattern of bone destruction.  Radiographic examination Pattern of bone destruction: Horizontal I Angular bone bone loss loss  P Radiographic examination A good bitewing radiograph: Superimposition of the buccal and lingual cusps. Well-defined alveolar crestal margin. No horizontal overlap between adjacent teeth  Radiographic examination Periapical radiographs in assessment of percentage bone loss A 3 mm Normal Bone 10 mm Level 21mm B C % Bone loss= = = 38.8 %  Radiographic examination Limitations of intraoral radiographs: ✓Roots of teeth obscure the extent of bone loss on the facial and lingual surfaces. ✓Dense facial and lingual cortical bone obscures crater-like defects. ✓Height of bone is distorted by improper x-ray angulation. ✓Trabecular pattern vary by modifying exposure and development time of the x-ray film.  Summary The periodontal examination is the basis from which the diagnosis, prognosis, and treatment plan are derived and from which treatment is ultimately rendered. Therefore a thorough and accurate periodontal examination is of the utmost importance.  References Newman and Carranza's Clinical Periodontology, Thirteenth Edition Chapter (3 & 32) Gehrig, Jill S, and Jill S. Gehrig. Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation. Philadelphia: Lippincott Williams & Wilkins  Thank you! [email protected]