CHAPTER 30: PERIODONTAL DIAGNOSIS

PERIODONTAL DIAGNOSIS

example of wasting diseases

erosion

abrasion

attrition

abfraction

erosion

aka: corrosion

it can be confined to enamel or underlying dentin and cementum

a wedge-shaped depression in the cervical area of a facial tooth, affecting a group of teeth

the cause is unknown, but calcification by acidic beverages or citrus fruits and acid salivary secretion are suggested

abrasion

tooth wear starts on exposed cementum surfaces and extends to root dentin, causing sharp "ditching" and tooth loss due to mechanical wear and brushing, as well as habits like holding objects between teeth

aggressive toothbrushing — the most common cause

tooth position (facial) — a major factor in the abrasive loss of the root surface

attrition

occlusal wear resulting from functional contacts with opposing teeth

such physical wear patterns may occur on incisal, occlusal, and approximal tooth surfaces

a certain amount of tooth wear is physiologic, but accelerated wear may occur when abnormal anatomic or unusual functional factors are present

occlusal wear in young adults is not age-related, but rather due to bruxing activity, rather than functional wear, suggesting that significant attrition in modern societies is not due to age-related factors

gradual attrition

may be compensated for by continuous tooth eruption without alveolar bone growth

is characterized by a lack of inflammatory changes on the alveolar bone surfaces

facets

occlusal or incisal surfaces worn by attrition

can cause enamel rod fractures and light-reflective discoloration

they vary in size and location, and are not sensitive to thermal or tactile stimulation

they can be treated with coronoplasty, but coronoplasty doesn't increase wear ratings

excessive wear may result in a flat or cuneiform occlusal surface

horizontal facets

tend to direct forces on the vertical axis of the tooth, to which the periodontium can adapt most effectively

angular facets

direct occlusal forces laterally and increase the risk of periodontal damage

3 best indicator of ongoing frictional activity

shiny

smooth

curviplanar facets

abfraction

results from occlusal loading surfaces causing tooth flexure and mechanical microfractures and tooth substance loss in the cervical area

dental stains

these are pigmented deposits on the teeth

they should be carefully examined to determine their origin

hypersensitivity

Root surfaces exposed by gingival recession may be hypersensitive to thermal changes or tactile stimulation.

Patients often direct the clinician to the sensitive areas.

These may be located by gentle exploration with a probe or cold air.

proximal contact relations

open contacts allow food impaction

the tightness of contacts should be checked by means of clinical observation and with dental floss

abnormal contact relationships may also initiate occlusal changes such as a shift in the median line between the central incisors, with labial flaring of the maxillary canine, buccal, or lingual displacement of the posterior teeth, and an uneven relationship of the marginal ridges

teeth opposite an edentulous site may super erupt, thus opening the proximal contacts

tooth mobility

healthy periodontium lessen these variations

primarily horizontal, with some axial mobility to a lesser extent

teeth have slight physiologic mobility, varying for different teeth and times of the day

morning mobility — greatest due to sleep-induced tooth extrusion

waking hours — reduced by chewing and swallowing forces

single-rooted teeth have more mobility than multirooted teeth, with incisors having the most

2 stages tooth mobitity occurs

initial / intrasocket stage

secondary stage

initial or intrasocket stage

the movement of a tooth in the buccolingual or mesiodistal direction (side to side) within the socket

movement is due to the elasticity of the periodontal ligament fibers.

secondary stage

vertical mobility

movement of the tooth in an axial direction (up and down) within the socket when pressure is applied

occurs gradually & entails elastic deformation of the alveolar bone in response to increased horizontal forces

2 stages of how the teeth return to their original position when a force is discontinued

immediate — springlike elastic recoil

slow — asymptomatic recovery movement

how does mobility graded clinically

by holding the tooth firmly between the handles of two metallic instruments or with one metallic instrument and one finger

an effort then is made to move it in all directions.

graded according to the ease and extent of tooth movement

faciolingually

abnormal mobility most often occurs in this position

grade I

slightly more than normal

grade II

moderately more than normal

grade III

severe mobility faciolingually and/or mesiodistally

combined with vertical displacement

abnormal or pathologic

the term used to refer mobility beyond the physiologic range

however, the periodontium is not necessarily diseased at the time of examination

factors increasing tooth mobility

periodontal surgery

trauma from occlusion

extension of inflammation

loss of tooth support (bone loss)

pathologic processes of the jaws

pregnancy / menstrual cycle / hormonal contraceptives

loss of tooth support (bone loss)

short, tapered roots are more likely to loosen

tooth mobility is influenced by bone loss severity, root size, and root shape

post-orthodontic cases should be evaluated for potential root shortening, as mobility severity doesn't always correlate with bone loss severity

Trauma from occlusion

an injury caused by excessive occlusal forces or abnormal habits, leading to tooth mobility

occurs initially due to bone resorption, causing reduced fiber support and later widened periodontal space

the diagnosis of trauma from occlusion is based on periodontal tissue condition, which can indicate the presence of trauma

periodontal findings suggest excessive tooth mobility, bone destruction, infrabony pockets, and pathological migration.

extension of inflammation

from the gingiva or from the periapex into the periodontal ligament results in changes that increase mobility.

the spread of inflammation from an acute periapical abscess may increase tooth mobility in the absence of periodontal disease.

periodontal surgery

temporarily increases tooth mobility immediately after the intervention and for a short period.

pregnancy / menstrual cycle / hormonal contraceptives

This is unrelated to periodontal disease and occurs presumably because of physicochemical changes in the periodontal tissues.

pathologic processes of the jaws

destroy the alveolar bone and the roots of the teeth can also result in mobility

osteomyelitis and tumors of the jaws belong in this category

pathologic migration of teeth

alterations in tooth position should be carefully noted, particularly with a view toward identifying abnormal forces, a tongue-thrusting habit, or other habits that may be contributing factors

premature tooth contacts in the posterior region cause maxillary anterior teeth periodontitis destruction and pathologic migration, leading to facial "flaring" due to increased trauma against the palatal surface.

pathologic migration of anterior teeth in young persons may be a sign of localized aggressive (juvenile) periodontitis.

sensitivity to percussion

a feature of acute inflammation of the periodontal ligament.

gentle percussion of a tooth at different angles to the long axis often aids in localizing the site of inflammatory involvement

dentition with jaws closed

this can detect conditions, such as irregularly aligned teeth, extruded teeth, improper proximal contacts, and areas of food impaction, all of which may favor plaque accumulation

excessive overbite

seen most often in the anterior region

may cause impingement of the teeth on the gingiva and food impaction

followed by gingival inflammation, gingival enlargement, and pocket formation

open bite

abnormal vertical spaces exist between the maxillary and mandibular teeth

the condition occurs most often in the anterior region, although posterior open bite is occasionally seen.

reduced mechanical cleansing by the passage of food may lead to accumulation of plaque, debris, calculus formation, and extrusion of teeth.

crossbite

may be bilateral or uni- lateral, or it may affect only a pair of antagonists

the normal relationship of the mandibular teeth to the maxillary teeth is reversed, with the maxillary teeth being lingual to the mandibular teeth

causes:

trauma from occlusion, food impaction

spreading of the mandibular teeth

associated gingival and periodontal disturbances

functional occlusal relationships

an important part of the diagnostic procedure

dentitions that appear normal when the jaws are closed may present marked functional abnormalities

examination of the periodontium

systematic dental examinations should start in the molar region and progress around the arch to avoid overemphasis on unusual findings

detecting gingival and periodontal disease is crucial

charts provide a guide for thorough examinations, treatment response evaluation, and recall comparisons

electronic clinical records have become increasingly used, offering rapid access to information and digital images

computerized dental examination systems use high-resolution graphics and voice-activated technology for easy data retrieval

plaque & calculus

supragingival plaque & calculus — can be detected using a calibrated probe

subgingival calculus — can be detected by checking each tooth surface with a no. 17 / no. 3 probe

radiographs may reveal calculus deposits, but not for thorough detection

warm air may be used to deflect the gingiva and aid in visualization of the calculus

gingiva

dry the gingiva for accurate observations, as moisture obscures detail

consider features like color, size, contour, consistency, and pain

evaluate deviations and note gingival disease distribution

use visual examination, instruments, and palpation to detect pathologic alterations and exudate

2 basic types of tissue response / changes

fibrotic

edematous

edematous tissue response

characterized by a smooth, glossy, soft, red gingiva

conservative management:

scaling, polishing, cleaning

fibrotic tissue response

the gingiva is more firm, stippled, and opaque

it is usually thicker, and the margin appears rounded

management such as gingivectomy

the most useful and most easily transferred to clinical practice

gingival index

sulcus bleeding index

gingival index (Löe and Silness)

provides an assessment of the gingival inflammatory status

it can also be used to compare the gingival status at recall visits

attaining good intra-examiner and inter-examiner calibration is imperative in the dental office

can be used in practice to compare gingival health before and after phase I therapy or before and after surgical therapy

sulcus bleeding index (Mühlemann and Son)

provides an objective, easily reproducible assessment of the gingival status

easily understood by patients, enhancing motivation for plaque control

the index assesses gingival status, detecting early inflammatory changes and lesions at the periodontal pocket base

periodontal pockets

examination for this must include their presence and distribution on each tooth surface, pocket depth, level of attachment on the root, and type of pocket (suprabony or infrabony).

probing

pockets can be detected through clinical signs like color changes, a rolled edge, enlarged gingiva, bleeding, suppuration, and loose teeth

they are generally painless but may cause symptoms like localized pain, pressure sensation, foul taste, sensitivity to hot and cold, and toothache without caries

careful exploration with a periodontal probe

only accurate method of detecting & measuring periodontal pockets

radiographs indicate bone loss but do not show pocket presence or depth

periodontal pockets are not detected by radiographic examination, as they are soft tissue changes

gutta percha points / calibrated silver points

can be used with the radiograph to assist in determining the level of attachment of periodontal pockets

they may be used effectively for individual pockets or in clinical research, but their routine use throughout the mouth would be difficult to manage.

clinical examination and probing are more direct and efficient.

2 different pocket depths

the biologic / histologic depth

the clinical / probing depth

the biologic / histologic depth

the actual distance between the gingival margin and the attached tissues (bottom of pocket)

this can be measured only in carefully prepared and adequately oriented histologic sections

the distance between the gingival margin and the base of the pocket (the coronal end of the junctional epithelium)

the clinical / probing depth

the distance to which a probe penetrates into the pocket

kung asa taman mu penetrate ang probe

top most to the most apical

pocket depth

the distance between the base of the pocket and the gingival margin

it may change from time to time even in untreated periodontal disease because of changes in the position of the gingival margin, and therefore it may be unrelated to the existing attachment of the tooth.

biologic width

cannot be measured by probing

CEJ to gingival margin

clinical attachment level

more accurate

from CEJ to base of the pocket

the distance between the base of the pocket and a fixed point on the crown such as the cementoenamel junction (CEJ)

changes can be the result of gain or loss of attachment and afford a better indication of the degree of periodontal destruction

subtracting

when the giingival margin is above the CEJ

the probing depth (gingival margin to base of the pocket) to the distance from the gingival margin to the CEJ

adding

when the gingival margin is below the CEJ

the probing depth (gingival margin to base of the pocket) to the distance from the gingival margin to the CEJ

determining the level of attachment when the gingival margin coincides with the CEJ

the loss of attachment equals the pocket depth.

determining the level of attachment when the gingival margin is located on the anatomic crown

determined by subtracting from the depth of the pocket the distance from the gingival margin to the CEJ

if both are the same, the loss of attachment is zero

determining the level of attachment when the gingival margin is located apical to the CEJ

the loss of attachment is greater than the pocket depth.

Therefore the distance between the CEJ and the gingival margin should be added to the pocket depth.

depth of penetration for healthy gingiva

penetrated the epithelium to about 2/3 of its length

depth of penetration for gingivitis

it stopped 0.1mm short of its apical end

depth of penetration for periodontitis

the probe tip consistently went past the most apical cells of the junctional epithelium

0.3 mm

depth of penetration in the connective tissue apical to the junctional epithelium in a periodontal pocket

0.75 N

probing force that can be tolerated

30g

the tip of the probe remains within the junctional epithelium

50g

necessary to reach the bone level

<1mm

Standardization of the probe tip

probing technique

parallel to the vertical axis of the tooth

“walked” circumferentially around each surface of each tooth to detect the areas of deepest penetration

to detect an interdental crater:

the probe should be placed obliquely from both the facial and lingual surfaces so as to explore the deepest point of the pocket located beneath the contact point

nabers probe

the use of this probe allows an easier and more accurate exploration of the horizontal component of furcation lesions

30-60 seconds after probing

the time to should recheck for bleeding

bleeding on probing

this test doesn't predict progressive attachment loss, but its absence is a reliable indicator of periodontal stability, and its presence in multiple sites of advanced disease is a good indicator.

initial probing

together with the clinical and radiographic examination

done to determine whether the tooth can be saved or should be extracted

after sufficient plaque control and removal of calculus, major inflammatory changes disappear, allowing for accurate probing of pockets

second probing

data obtained from this probing provides valuable information for treatment decisions

done to accurately establish the level of attachment and degree of involvement of roots and furcations

later in periodontal treatment, probings are done to determine changes in pocket depth and to ascertain healing progress after different procedures

plastic periodontal probes

should be used for implant instead of the steel probes used for the natural dentition to prevent scratching of the implant surface

the bacterial flora of a healthy gingival sulcus

coccoid cells

the bacterial flora of a periodontal pocket

greater number of spirochetes & motile bacteria

width of the attached gingiva

usually insufficient when stretching the lip or cheek

determined by subtracting the pocket depth from the total gingiva width

other methods include pushing the mucosa coronally or painting it with Schiller's potassium iodide solution

gingival recession

from the CEJ to the gingival crest

transgingival probing

performed after the area is anesthetized

a more accurate method of evaluation and provides additional information on bone architecture

palpation

doing this in the lateral and apical areas of the tooth may help locate the origin of radiating pain that the patient cannot localize.

Infection deep in the periodontal tissues and the early stages of a periodontal abscess may also be detected by palpation.

supparation

neutrophils in gingival fluid transform into purulent exudate, which is associated with periodontitis progression but not a good indicator

digital pressure can be used but is not enough to determine the presence of purulent exudate, which is formed in the inner pocket wall and may not be present in all periodontal pockets

periodontal abscess

a localized accumulation of exudate within the gingival wall, often acute or chronic

clinical evidence includes continuity with the gingival margin and may be located at a different root surface due to impaired drainage

acute periodontal abscess

more difficult to treat

the gingiva is edematous, red, and can vary in shape and consistency

appears as an ovoid elevation of the gingiva along the lateral aspect of the root

symptoms:

throbbing, pain, tenderness, tooth sensitivity, mobility, lymphadenitis, fever, leukocytosis, and malaise

chronic periodontal abscess

the sinus tract leads into the periodontium, covered by granulation tissue

asymptomatic, patients may experience gnawing pain, tooth elevation, and grinding

a sinus opening onto the root of the tooth, with intermittent exudation, may appear as a pinpoint opening

location & history of gingival abscess

confined to the marginal gingiva

it often occurs in previously disease-free areas

usually an acute inflammatory response to forcing of foreign material into the gingiva

location & history of periodontal abscess

involves the supporting periodontal structures

generally occurs in the course of chronic destructive periodontitis

periapical abscess

if the tooth is nonvital

may spread along the lateral aspect of the root to the gingival margin

a radiolucent area along the lateral surface of apical rarefaction suggests this

however, a previously nonvital tooth can have a deep periodontal pocket that can abscess