Comprehensive Periodontal and Oral Examination Guide for Dental Hygiene Students

Anatomic crown

Part of the tooth covered by enamel

Anatomic root

Part of the tooth covered by cementum

Clinical crown

Part visible above the gingiva (supragingival)

Clinical root

Part below the gingiva, not visible (subgingival)

CEJ (cementoenamel junction)

Where cementum meets enamel; fixed landmark used for GM and CAL

Enamel

Hard outermost layer covering the anatomic crown

Dentin

2nd layer beneath enamel and cementum; contains tubules

Cementum

Calcified connective tissue covering the root; attachment for the PDL

Pulp

Soft innermost layer (blood vessels, nerves, cells)

Gingiva

Keratinized, firmly attached tissue

Alveolar mucosa

Movable, loosely attached to bone, smooth and shiny, thin nonkeratinized epithelium

Periodontium

Functional unit of tissues that surrounds and supports the tooth

Cementum (function)

Seals the tubules of root dentin; attachment for PDL fibers

Periodontal ligament (PDL)

Fibrous connective tissue attaching root to alveolar bone

Alveolar bone

Bone forming the tooth sockets; supports teeth and anchors PDL fibers

Gingival margin (GM)

Edge of the gingiva nearest the incisal or occlusal surface

Free (marginal) gingiva

Loose, unattached gingiva on facial/lingual/palatal; follows the scalloped CEJ contour

Free gingival groove

Shallow linear groove separating free gingiva from attached gingiva

Gingival sulcus

Space between free gingiva and tooth; contains gingival crevicular fluid (GCF)

Junctional epithelium (JE)

Cuff-like band of stratified squamous, nonkeratinized epithelium that encircles the tooth

Interdental papilla

Soft triangular tissue between two adjacent teeth in contact

Col

Depression between the facial and lingual papillae, apical to the contact area

Attached gingiva

Keratinized gingiva from the free gingival groove to the MGJ

Mucogingival junction (MGJ)

Line between attached gingiva and alveolar mucosa

Frenum

Narrow fold of mucous membrane connecting movable tissue to fixed tissue

Probing depth (PD)

From the gingival margin to the junctional epithelium; recorded at 6 sites per tooth

BOP

Bleeding on gentle probing; sign of gingival inflammation

Suppuration

Infection (pus) that can be expressed from the pocket with a probe

Clinical attachment level (CAL)

True measurement of periodontal support measured from a fixed point (the CEJ)

Mobility

Loosening of a tooth due to loss of support (alveolar bone and PDL)

Furcation

Where the roots of a multirooted tooth fork or separate

Class I Furcation

Concavity just above the furcation entrance can be felt; probe cannot enter.

Class II Furcation

Probe enters more than 1 mm but cannot pass completely through.

Class III Furcation

Probe passes completely through between the roots.

Class IV Furcation

Same as Class III, but the furcation is visible clinically due to recession.

MGJ

Junction between attached gingiva and alveolar mucosa; visible by change in color and consistency.

Width of Attached Gingiva

Step 1, measure total width of gingiva (GM to MGJ). Step 2, measure PD. Step 3, attached gingiva = total width − PD.

Mucogingival Involvement (MGI)

2 mm or less of attached gingiva.

Documenting MGI

MGI is documented in the clinical note with the gingival description, NOT on the perio chart.

Explorer

An assessment instrument used to determine tooth anatomy and surface texture by touch.

Uses of an Explorer

Detect calculus, surface irregularities, restoration margin defects; examine anomalies and anatomy; assess restorations and sealants.

Explorer Design

Flexible metal that conducts vibrations; circular in cross-section; paired or unpaired working ends.

Working End of Explorer

Tip is 1-2 mm long; the actual point is never used to detect calculus.

Pigtail / Cowhorn Explorer

Curved, paired; used for proximal surfaces, normal or shallow pockets.

Orban-type Explorer

Straight lower shank; used for insertion into narrow pockets.

11/12-type Explorer

Tip at 90° to the lower shank; used for anterior and posterior teeth.

Feeling Stroke Technique

Relaxed grasp; middle finger rests lightly on the shank.

Lateral Pressure for Assessment

Feather-light pressure is recommended.

Common Errors in Assessment

'Death grip' on the handle; pressing with the middle finger on the shank.

Calculus Deposit Types

Spicules, ledges, rings, and veneers.

Spicules

Isolated, minute particles found under contact areas.

Ledge

Long ridge parallel to the gingival margin; common on all surfaces.

Ring

Ridge parallel to the GM that encircles the entire tooth.

Veneer

Thin, smooth, shield-shaped coating on a portion of the root surface.

ODU 11/12 Working-End Selection

Universal due to long complex shank and 90° tip for anterior and posterior teeth.

Anterior Sequence for Right-handed

Maxillary from 9:00; mandibular from 8:00.

Posterior Sequence Steps

Includes getting ready, inserting, repositioning, exploring facial, and continuing tooth by tooth.

Rationale for Oral Examination

Early identification of abnormalities, especially oral cancer.

Oral Cancer Risk Factors

Age, gender, sun exposure, tobacco, alcohol, diet, precancerous lesions, HPV.

Risk factors

Age, gender, sun exposure, tobacco and smokeless tobacco, alcohol, diet, precancerous lesions, organ/bone marrow transplant, HPV, genetic predisposition.

Categories of diagnosis

Clinical, historical, surgical, laboratory, radiographic, microscopic, therapeutic, differential.

Sign

Objective, observed by the provider.

Symptom

Subjective, reported by the patient.

Visual examination

Direct observation (color, contour, size, movement); radiographs; transillumination (strong light through tissue or tooth).

Palpation

Touch with the palmar surfaces of the fingertips.

Instrumentation

Periodontal probe, explorer.

Percussion

Tapping a tooth or surface with finger or instrument.

Electrical test

Electric pulp tester: vital vs. nonvital pulp.

Auscultation

Listening, e.g. TMJ clicking on opening/closing.

Digital palpation

One finger.

Bidigital palpation

Finger + thumb of the same hand.

Bimanual palpation

Fingers/thumb of each hand together in coordination.

Bilateral palpation

Two hands at the same time on both sides.

Compression techniques

Between fingers of one hand (sternomastoid muscle); between fingers of both hands (buccal mucosa, one finger inside and one outside); against an underlying structure (supraclavicular nodes).

Palpation findings

Surface (smooth/rough, flat/raised), shape (irregular, round, oval), consistency (firm, hard, spongy), mobility (mobile vs. fixed), tenderness.

Keys to an effective exam

S.I.P.D. = Sequence (same order every patient), Inspect first, Palpate well, Document everything.

EOE positioning

Patient seated upright, head against the headrest; clinician stands in front for overall appraisal and behind for lymph node palpation.

IOE sequence

Lips & vermilion border, oral cavity & mucosal surfaces, underlying structures of lips & cheeks, floor of the mouth, salivary gland function, tongue, palate, tonsils, oropharynx.

Normal lips

Lips touch at rest; smooth, intact, normal color.

Notable lips

Chapped/cracked, pigment changes, herpetic lesions, swelling, trauma/lip biting.

Normal oral cavity

Smooth, intact, coral pink to bluish brown; intact frenums.

Notable oral cavity

Color/texture change, swelling, trauma, lesions.

Normal tongue

Moist, pink, papillae present, symmetrical.

Notable tongue

Red patches with a white/yellow border; pattern changes.

Macule

Flat, not raised (e.g., freckle).

Vesicle

Small fluid-filled elevated lesion.

Bulla

Fluid-filled blister larger than 5 mm.

Sessile

Broad, flat base.

Pedunculated

Attached by a stalk.

Fordyce granules

Tiny yellow papules in clusters; ectopic sebaceous glands.

Torus palatinus

Bony exophytic growth of normal compact bone.

Mandibular tori

Bony outgrowths of dense bone.

Leukoedema

Gray-white opalescent film that fades when stretched.