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Comprehensive Periodontal Examination (CPE) Overview

The Comprehensive Periodontal Examination (CPE) is a systematic method of recording a patient's existing periodontal health status. It serves as the definitive standard for diagnosis and treatment planning.

Primary Purposes of the CPE

• Systematic Documentation: To record the patient's existing periodontal condition.

• Clinical Utility: The information is utilized for diagnosis and formulating a comprehensive treatment plan.

• Re-evaluation: To assess how a patient responds to periodontal treatment at various stages.

• Long-term Monitoring: To track health or disease progression over time.

Indications for Performing a CPE

• New Patients: All patients new to the facility.

• Transfer Patients: Any patient transferring from another provider.

• Recurring Requirement: Previously treated periodontitis patients must undergo a full CPE at least once every year.

Core Goals

1. Establish a definitive periodontal diagnosis.

2. Determine the periodontal prognosis.

3. Create a structured treatment plan.

4. Obtain a baseline value for every new patient.

Clinical Documentation and the Axium Management System

Clinical findings for the CPE are recorded in the Axium patient management system. Students are expected to undergo specific Axium training to navigate the system effectively.

Documentation Resources

• Detailed instructions for creating a new Periodontal Examination Form and charting clinical findings are located in the CCP Manual.

• The UG Perio Exam TP Form and Perio Charting interface allow for recording complex data including Probing Depths (PD), Free Gingival Margin (FGM), Attachment levels, Width of keratinized tissue, Furcation involvement, Bleeding, Mobility, and Suppuration.

• Help Feature: Clicking the green question mark ($?$) at the bottom left of the Axium form provides additional guidance for filling out specific fields.

Step 1: Dental History and Oral Hygiene Assessment

A comprehensive history is the first step in the periodontal assessment process.

History of Previous Periodontal Treatments

• Inquiry regarding "deep cleanings" or scaling and root planing.

• Use of local anesthesia during previous cleanings.

• Past use of antibiotics for periodontal abscesses.

• History of periodontal surgeries.

History of Missing Teeth

It is critical to determine why teeth were removed. Common reasons include:

• Periodontal disease.

• Caries (tooth decay).

• Trauma.

• Vertical root fracture.

• Orthodontic extraction.

• Congenital absence.

Home Care Assessment

• Frequency: Frequency of brushing and flossing.

• Oral Care Aids: Use of mouthwash, toothpicks, interdental brushes, or other specific cleaning tools.

• Cleaning History: Date of the last professional cleaning and the general frequency of cleanings.

Plaque and Calculus Assessment

Clinicians must record the presence, degree, and distribution of both plaque/biofilm and calculus.

Plaque Index (Silness & Loe 1964)

While not specifically used for charting in the Axium system, the Silness & Loe index provides a standardized way to quantify plaque accumulation.

• Score $0$: No plaque present.

• Score $1$: A thin film of plaque at the gingival margin, visible only when scraped with an explorer.

• Score $2$: A moderate amount of plaque along the gingival margin; the interdental space is free of plaque; plaque is visible to the naked eye.

• Score $3$: Heavy plaque accumulation at the gingival margin; the interdental space is filled with plaque.

Step 2: Comprehensive Periodontal Charting (Clinical Findings)

Charting involves a detailed assessment of the periodontium for every tooth in the dentition.

Probing Depth (PD)

• Measurement: $6$ sites per tooth are measured (mesio-buccal, mid-buccal, disto-buccal, mesio-lingual/palatal, mid-lingual/palatal, and disto-lingual/palatal).

• Force: A pressure of $20-25\,g$ ($0.20-0.25\,N$) should be used to minimize patient discomfort.

• Technique: The probe should normally be held parallel to the root surface and parallel to the long axis of the tooth.

• Overestimation Causes: Excessive pressure during probing.

• Underestimation Causes: Improper probe angulation, probe not parallel to the root or long axis, presence of calculus obstructing the probe, or pressure that is too light.

• Radiographic Correlation: Significant probing depths clinically should correlate with radiographic bone loss. Conversely, if significant bone loss is seen on a radiograph, significant clinical probing depths are expected.

Free Gingival Margin (FGM) and Recession

• Measurement: The distance from the Cemento-Enamel Junction (CEJ) to the gingival margin.

• Sites: $6$ sites per tooth.

• Negative Recession: If the gingival margin is coronal to the CEJ (covering the CEJ), it is recorded as "negative recession."

Clinical Attachment Level (CAL)

• Formula: $\text{Probing Depth} + \text{Recession}$.

• Note: This is automatically calculated in the system, but the clinician must interpret the findings to determine if true clinical attachment loss has occurred.

Width of Keratinized Tissue and Gingival Anatomy

Measurements for keratinized tissue are taken from the gingival margin to the Mucogingival Junction (MGJ). Only one value (at the mid-buccal) is recorded per tooth.

Recording Conventions in Axium

• Enter 0: Used when there is $< 1\,mm$ of Keratinized Tissue (KT) or no Attached Gingiva (AG).

• Enter 1: Used when there is $< 2\,mm$ of KT or $1\,mm$ of AG.

• Leave Blank: Used when there is $\ge 2\,mm$ of KT or $1\,mm$ of AG.

Anatomical Landmarks Review

• Gingival Margin: The edge of the gingiva surrounding the tooth.

• Gingival Sulcus: The space between the tooth and the free gingiva.

• Junctional Epithelium: The epithelium that attaches the gingiva to the tooth.

• Free Gingival Groove: A shallow line or depression that separates the free gingiva from the attached gingiva.

• Attached Gingiva: The part of the gingiva that is firm, resilient, and tightly bound to the underlying periosteum of alveolar bone.

• Mucogingival Junction (MGJ): The boundary between the attached gingiva and the alveolar mucosa.

• Alveolar Mucosa: The thin, vascular, moveable tissue apical to the attached gingiva.

Furcation Involvement Analysis

Furcation involvement refers to the invasion of periodontal disease into the area between the roots of multi-rooted teeth.

Measurement Locations

• Maxillary Molars: Checked at $3$ sites (one buccal entrance and two palatal/interproximal entrances).

• Mandibular Molars: Checked at $2$ sites (one buccal and one lingual).

• Maxillary 1st Premolars: Can also have furcation involvement. The average distance from the mesial CEJ to the furcation is $7.9\,mm$.

Anatomical Factors

• Cervical Enamel Projection (CEP): An extension of enamel toward the furcation. Common in Mandibular 2nd molars ($7$s). Approximately $82.5\%$ of molars with CEP have furcation involvement, compared to only $17.5\%$ without.

• Enamel Pearl: Most common in Maxillary 3rd molars ($8$s); prevalence is $2.7\%$.

Specific Furcation Entrance Measurements

• Maxillary Molars:

  • Mesial furcation entrance: $3.6\,mm$

  • Facial furcation entrance: $4.2\,mm$

  • Distal furcation entrance: $4.8\,mm$

• Mandibular Molars:

  • Facial furcation entrance: $2.4\,mm$

  • Lingual furcation entrance: $2.5\,mm$

Classifications of Furcation

• Hamp's Classification (Standard at U of T): Based on horizontal penetration measured with a Naber's probe relative to an imaginary tangent line.

  • Grade I: Horizontal penetration $\le 3\,mm$.

  • Grade II: Horizontal penetration $> 3\,mm$ (not through and through).

  • Grade III: Through and through lesion.

• Glickman's Classification:

  • Grade I: Pocket into the flute; intact interradicular bone.

  • Grade II: Loss of interradicular bone; varying depths into the furca.

  • Grade III: Through and through lesion, but not clinically visible.

  • Grade IV: Through and through lesion that is clinically visible due to recession.

• Tarnow and Fletcher's Classification (Vertical Depth):

  • Class A: $1-3\,mm$ probeable vertical depth.

  • Class B: $4-6\,mm$ probeable vertical depth.

  • Class C: $> 6\,mm$ probeable vertical depth.

Mobility, Bleeding, and Suppuration

Bleeding on Probing (BOP)

• Measured at $6$ sites per tooth.

• Papillary Bleeding Index (Muehlemann 1977) for Reference:

  1. A single discrete bleeding point.

  2. Several isolated bleeding points or a single line of blood.

  3. Interdental triangle fills with blood.

  4. Profuse bleeding.

Tooth Mobility (Miller Classification)

• Class 0: "Physiologic" mobility ($0.1-0.2\,mm$ horizontal).

• Class 1 (M1): $< 1\,mm$ movement in a buccal-lingual (BL) or mesial-distal (MD) direction.

• Class 2 (M2): $\ge 1\,mm$ movement in a BL or MD direction.

• Class 3 (M3): $\ge 1\,mm$ movement in BL/MD directions AND apical direction ("depressible").

Suppuration

Suppuration (pus formation) is recorded if present upon probing.

Step 3: Occlusal Analysis

The occlusal analysis evaluates the functional relationship between the teeth.

• Maximum Intercuspation Interferences: Obstructions during closing into the tightest fit.

• Working Side Contacts: Contacts on the side the mandible moves toward.

• Non-working Side Contacts: Contacts on the side the mandible moves away from.

• Protrusive Contacts: Contacts during the forward movement of the mandible.

• Wear Facets: Specific patterns of tooth wear caused by attrition.

• Fremitus: The palpable movement or vibration of a tooth or teeth upon closure.

Completion of the CPE Process

Following the clinical assessment, the clinician must perform the following steps to complete the CPE:

• Step 4: Assess Dentition: Evaluate general dental health (e.g., caries, restorations).

• Step 5: Assess Radiographs: Review x-rays for bone loss and pathology.

• Step 6: Periodontal Risk Assessment: Determine the patient's likelihood of disease progression.

• Step 7: Establish Diagnosis: Define the specific periodontal disease state.

• Step 8: Establish Periodontal Prognosis: Forecast the likely outcome for individual teeth or the overall dentition.

Periodontal Screening and Recording (PSR)

The PSR is a swift, cost-effective diagnostic screening tool launched in 1993 and endorsed by the ADA and AAP for the early detection of periodontal disease.

PSR Tool Features

• Tip: $0.5\,mm$ balled tip.

• Band: Colour-coded band located between $3.5\,mm$ and $5.5\,mm$.

PSR Procedure

1. Examine $6$ sites on every tooth.

2. Assign the highest score ($0-4$) recorded in each sextant.

3. If a Code 4 is reached, the clinician may move immediately to the next sextant.

4. The symbol * is added to indicate clinical abnormalities (furcations, mobility, mucogingival problems, or recession $\ge 3.5\,mm$).

PSR Scoring Criteria

• Code 0: Band fully visible; no calculus/defective margins; healthy tissues; no BOP. (Tx: Preventive care).

• Code 1: Band fully visible; no calculus/margins; BOP present. (Tx: OHI, subgingival plaque removal).

• Code 2: Band fully visible; supra- or sub-gingival calculus present and/or defective margins. (Tx: OHI, calculus/plaque removal, correction of restorations).

• Code 3: Band partly visible ($3.5-5.5\,mm$ probing depth). (Tx: Comprehensive exam of this sextant; if $\ge 2$ sextants have Code 3, a full CPE is required).

• Code 4: Band disappears ($> 5.5\,mm$ probing depth). (Tx: Full-mouth CPE required).

Differentiating Between CPE and PSR Utilization

Use Case: CPE

• All New Patients.

• All Transfer Patients.

• Previously treated periodontitis patients: Must have a CPE every year.

• Required to establish the initial diagnosis, prognosis, and risk assessment.

Use Case: PSR

• Periodontal Recall Patients: For those previously diagnosed as healthy or with gingivitis on an intact periodontium.

• Reduced Periodontium: For patients with a healthy/gingivitis status on a reduced periodontium who present before their required 1-year annual CPE.

• Note: If active periodontal disease is identified during a PSR recall, the patient is removed from maintenance and a full CPE is performed to re-enter treatment.