Periodontal Examination and Diagnosis PDF

Periodontology Dr. Reham Adnan Radhi Periodontal Examination and Diagnosis Lec.1,2 Proper diagnosis is essential to intelligent treatment. Periodontal diagnosis should first determine whether disease is present...

Periodontology Dr. Reham Adnan Radhi Periodontal Examination and Diagnosis Lec.1,2 Proper diagnosis is essential to intelligent treatment. Periodontal diagnosis should first determine whether disease is present. It should then identify the disease, and its severity and extent. Finally, it should provide an understanding of the underlying pathologic processes and their cause. The periodontal diagnosis is determined after careful analysis of the case history and evaluation of the clinical signs and symptoms as well as the results of various diagnostic procedures (e.g., probing, mobility assessment, radiographs, blood tests, and biopsies). The following is a recommended sequence of procedures for the diagnosis of periodontal diseases.  Overall Appraisal of the Patient From the first meeting, the clinician should attempt an overall appraisal of the patient. This includes consideration of the patient’s mental and emotional status, temperament, attitude, and physiologic age.  Health History Most of the health history is obtained at the first visit The importance of the health history should be clearly explained, because patients often omit information that they cannot relate to their dental problems. The patient should be made aware of the following: (1) The possible impact of certain systemic diseases, conditions, behavioral factors, and medications on periodontal disease, its treatment, and treatment outcomes; (2) The presence of conditions that may require special precautions or modifications of the treatment procedure. (3) The possibility that oral infections may have a powerful influence on the occurrence and severity of a variety of systemic diseases and conditions. 1|P a g e The health history should include reference to the following: 1. If the patient is under the care of a physician, the nature and duration of the problem and its therapy should be discussed. The name, address, and telephone number of the physician should be recorded, because direct communication with him or her may be necessary. 2. Details regarding hospitalizations and operations, including the diagnosis, the type of operation, and any untoward events (e.g., anesthetic, hemorrhagic, or infectious complications) should be obtained. 3. All medical problems (e.g., cardiovascular, hematologic, endocrine), including infectious diseases, sexually transmitted diseases, high-risk behavior for human immunodeficiency virus infection, and possible occupational disease, should be inquired. 4. Abnormal bleeding tendencies, such as nose bleeds, prolonged bleeding from minor cuts, spontaneous ecchymosis, a tendency toward excessive bruising, and excessive menstrual Bruises bleeding, should be cited. These symptoms should be correlated with the medications that the patient is taking. 5. Information is needed for females regarding the onset of puberty, menopause, menstrual disorders, hysterectomy, pregnancies, and miscarriages. Hysterectomy cervix. is the surgical removal of the uterus and 6. A list of all medications being taken. All of the possible effects of these medications should be carefully analyzed to determine their effect. Special inquiry should be made regarding the dosage and duration of therapy with anticoagulants and corticosteroids. Patients who are taking any of the family of drugs called bisphosphonates (e.g., Actonel, Fosamax, Boniva, Aredia, Zometa), which are often prescribed for osteoporosis, should be cautioned about possible problems related to osteonecrosis of the jaw after undergoing any form of oral surgery involving bone. 7. The patient's allergy history should be taken, including that related to hay fever, asthma, sensitivity to foods, sensitivity to drugs (e.g., aspirin, codeine, barbiturates, sulfonamides, antibiotics, procaine, laxatives), and sensitivity to dental materials (e.g., latex, eugenol, acrylic resins). 8. A family history should be taken, including that of bleeding disorders, cardiovascular disease, diabetes, or periodontal diseases. 9. Detailed information on current and history of alcohol, recreational drugs, and tobacco use, and desire to quit should be elicited. Recreational drugs are chemical substances taken for enjoyment rather than for medical reasons. 2|P a g e   Dental History 1. Visits to the dentist should be listed, including their frequency, the date of the most recent visit, the nature of the treatment, and oral prophylaxis or cleaning by a dentist or hygienist, including the frequency and date of most recent cleaning. 2. The patient’s oral hygiene regimen should be described, including tooth brushing frequency, time of day, method, type of toothbrush and dentifrice, and interval at which brushes are replaced. Other methods for mouth care, such as mouthwashes, interdental brushes, other devices, water irrigation, and dental floss, should also be listed. 3. Any orthodontic treatment, including its duration and the approximate date of termination, should be noted. 4. If the patient is experiencing pain in the teeth or in the gingiva, the manner in which the pain is provoked, its nature and duration, and the manner in which it is relieved should be described. 5. Note the presence of any gingival bleeding, including when it first occurred; whether it occurs spontaneously, on brushing or eating, at night. 6. A bad taste in the mouth and areas of food impaction should be mentioned. 7. If the patient has any difficulty chewing, and whether there is any tooth mobility. 8. Note the patient’s general dental habits, such as grinding or clenching of the teeth during the day or at night, tobacco smoking or chewing, nail biting. 9. Discuss the patient’s history of previous periodontal problems, including the nature of the condition, and, if it was previously treated, the type of treatment received (surgical or nonsurgical). 10. Note whether the patient wears any removable prosthesis. 11. Does the patient have implants to replace any of the missing teeth.  Social history 1. Details of habits such as tobacco use, including smokeless tobacco and alcohol consumption. 2. A social history may also give information about the patient’s occupation that is both useful for interacting with the patient and may indicate specific dental issues. 3|P a g e   Casts Casts from dental impressions are useful adjuncts during the oral examination which show the: - o The position of the gingival margins (recession). o Indicate the position and inclination of the teeth. o The proximal contact relationships. o The food impaction areas. o Cast provide a view of the lingual–cuspal relationships. o Casts are important records of the dentition before it is altered by treatment. o serve as visual aids during discussions with the patient, and they are useful for pre- treatment and post-treatment.  Intraoral Radiographic Survey The radiographic survey should consist of a minimum of 14 intraoral films and 4 posterior bite-wing films. Panoramic radiographs are a simple and convenient method of obtaining a survey view of the dental arch and the surrounding structures. They are helpful for the detection of developmental anomalies, pathologic lesions of the teeth and jaws, and fractures as well as for the dental screening examinations of large groups. They provide an information about the distribution and severity of bone destruction with periodontal disease.  Clinical Photographs Color photographs are useful for recording the appearance of the tissue before and after treatment. Photographs cannot always be relied on for comparing subtle color changes in the gingiva, but they do depict gingival morphologic changes. With the advent of digital clinical photography, record-keeping for mucogingival problems, such as areas of gingival recession, frenum involvement, and papilla loss has become important. Clinical Examination  Examination of Extraoral Structures: - Clinical examination should begin with an evaluation of the extraoral structures for abnormalities 1. The temporomandibular joints should be assessed for pain, crepitus, clicking, and range of motion. Crepitus is a palpable or audible grating or crunching sensation produced by motion. 2. The muscles of mastication should be palpated for pain and tenderness. 4|P a g e  3. lymph node of the head and neck: - Patients are often aware of the presence of “swollen glands. In” Primary herpetic gingivostomatitis, necrotizing ulcerative gingivitis, and acute periodontal abscesses may produce lymph node enlargement. After successful therapy, lymph nodes return to normal in a matter of days to weeks.  Examination of the Oral Cavity The entire oral cavity should be carefully examined, beginning with 1. Oral hygiene: - the accumulated of food debris, biofilm, calculus, stains as well as biofilm coating of the dorsum of the tongue (however the quantity of dental plaque is not necessarily related to the severity of the disease present, e.g. in aggressive periodontitis). 2. Oral malodor, which is also termed fetor ex ore, fetor oris, or halitosis. 3. The lips, the floor of the mouth, the tongue, the palate, the vestibule, and the oropharyngeal region should be evaluated for abnormalities and pathologies. 4. The oral mucosa in the lateral and apical areas of the tooth may be palpated for tenderness to detect periapical and periodontal abscesses.  Examination of the Periodontium The periodontal examination should be systematic and should not immediately begin with insertion of the periodontal probe into the gingival crevice, which can be uncomfortable and traumatic for a patient and may induce bleeding that may make visualization of inflammatory changes in the soft tissue challenging. Once a thorough visual periodontal assessment has been completed, the gingiva, the gingival crevice, and the subgingival tooth surface are carefully probed. Examination of the periodontium consists of two parts: visual examination and tactile examination. 5|P a g e Visual Periodontal Examination Visual examination begins with drying the tissue and taking a survey of biofilm and calculus accumulation to assess oral hygiene as well as clinical signs of inflammation (erythema, edema, etc.) and recession to assess the presence and severity of disease.  Visual Examination of Biofilm and Calculus There are many methods available for assessing biofilm and calculus accumulation 1. Directly observed: - Biofilm frequently accumulates in concavities along the gingival margins and embrasure spaces, especially in difficult-to-reach places, such as the lingual surfaces of the mandibular molars. Supragingival calculus commonly accumulates on the lingual surfaces of the mandibular anterior teeth and the buccal surfaces of the maxillary molars due to the presence of the respective Wharton and Stensen salivary ducts (The absence of biofilm may not necessarily indicate that the patient had good oral hygiene). 2. Careful probing of the root surface: - Most of the time, subgingival calculus will need to be detected by careful probing of the root surface. 3. Radiographs may sometimes reveal heavy calculus.  Visual Examination of the Gingiva Evaluation of the gingiva requires the tissue to be dried before accurate observations can be made. The presence of saliva can obscure details. Once the gingiva is thoroughly dried with gauze, it is evaluated and assessed for inflammatory changes. Subtle inflammatory changes in the marginal gingiva may be best detected by comparing the marginal gingiva to the gingival tissue 2 or 3 mm away from the gingival margin, where the tissue is likely to be heathy. 6|P a g e  Saliva obscures details. (A) The gingiva appears smooth when covered in saliva. (B) Once dried, stippling is visible, and erythema and edema become more obvious Probing Depth There are two different pocket depths: (1) The biologic or histologic depth (2) The clinical or probing depth. Biologic depth: is the distance between the gingival margin and the base of the gingival crevice (i.e., the coronal end of the junctional epithelium). This can be measured only in carefully prepared and adequately oriented histologic sections. Probing depth: is the distance from the gingival margin to the bottom of the probeable crevice (i.e., where the probe tip stops). Pocket probing depend on:  The force of introduction.  The shape and size of the probe tip.  The direction of penetration.  The resistance of the tissues.  The convexity of the crown.  The degree of tissue inflammation. A) In a normal sulcus, the probe penetrates about one-third to half the length of the junctional epithelium (between arrows). (B) In an inflamed periodontal pocket, the probe penetrates beyond the apical end of the junctional epithelium (between arrows). 7|P a g e