lecture recording on 12 March 2025 at 17.21.50 PM

Horizontal Bitewing Imaging

• Limited diagnostic value for periodontal conditions

  • Can observe bone level and alveolar crest, allowing clinicians to assess the general health of the alveolar bone.

  • Important to identify the relationship to the Cementoenamel Junction (CEJ), as this assists in evaluating periodontal disease progression.

• Preferred imaging method for periodontal conditions: Periapical (PA) radiographs

  • Provides more detailed information about the root structures, supporting tissues, and the extent of bone loss compared to bitewing images.

• Recommendation of using vertical bitewing in suspected periodontal cases

  • Vertical bitewings provide a better view of the bone levels interproximally compared to horizontal views, aiding in diagnosis.

  • Panoramic images offer minimal diagnostic value for periodontal assessment due to their broad perspective that may obscure localized issues.

Importance of Clinical Findings

• Clinical assessment is paramount alongside radiographs to form a comprehensive view of periodontal health.

  • Radiographs provide a 2D representation of complex 3D structures (e.g., furcations) which may not fully depict the clinical situation.

  • Furcations in lower molars: observed buccal-lingually; in maxillary molars: evaluated mesial-distally, with some possible palatal involvement that can complicate treatment decisions.

  • Measuring furcation depth with a furcation probe is critical for accurate diagnosis and prognosis, enabling targeted treatment planning.

Interpretation of Periodontal Disease

• Evaluation based on:

  • Bone loss patterns are integral in assessing the severity and type of periodontal disease:

    • Horizontal bone loss: occurs evenly and remains level with the adjacent CEJ, often indicative of generalized chronic periodontitis.

    • Vertical bone loss: characterized by its progression down the root, not parallel to the CEJ, associated with localized aggressive forms of periodontal disease.

  • Classification of periodontal conditions into specific categories allows for standardized treatment approaches.

  • Identifying predisposing or modifying factors affecting periodontal health is essential for personalized patient care and effective management of the disease.

Classification of Bone Loss

• Describe patterns & distribution:

  • Horizontal bone loss: measured against CEJ levels, useful for identifying areas of uniform loss.

  • Vertical bone loss: presents as radiolucent areas along the root surface, typically indicating more severe periodontal degradation.

• Distribution:

  • Localized: isolated to less than 30% of the mouth, which requires focused intervention to halt disease progression.

Severity of Bone Loss

• Old classification:

  • Slight: 1-2 mm bone loss, often manageable with basic hygiene and monitoring.

  • Moderate: 3-4 mm bone loss, may require scaling and root planing to restore health.

  • Severe: greater than 5 mm bone loss, necessitating surgical intervention or advanced treatments.

• Measurement by clinical attachment loss (CAL), assessing junctional epithelium migration, is crucial for understanding the degree of periodontal tissue destruction.

AAP Classification of Periodontal Disease (2017)

• Levels of periodontal disease:

  • Stage 1: less than 15% bone loss with 1-2 mm CAL; typically reversible with therapeutic intervention.

  • Stage 2: 15-33% bone loss involving the coronal third with 3-4 mm CAL; requires more comprehensive care strategies.

  • Stage 3: significant bone loss to the middle third or beyond; CAL of 5 mm or more indicates a need for aggressive management and possibly regenerative treatments.

  • Stage 4: severe damage similar to stage 3 but with additional factors such as tooth mobility, missing teeth, and occlusal trauma that complicate treatment and management.

Factors Impacting Periodontal Disease

• Local irritants

  • Calculus formation and defective restorations (overhanging margins) can exacerbate diseases by providing a surface for bacterial growth.

  • Crowding increases biofilm accumulation, making effective oral hygiene more challenging.

• Systemic factors

  • Medications, particularly those causing xerostomia (dry mouth), can contribute to plaque accumulation and periodontal disease.

  • Tobacco use impedes healing by diminishing blood flow to periodontal tissues.

  • Diabetes significantly influences periodontal healing dynamics, necessitating a multidisciplinary approach to care.

Radiographic Identification of Calculus

• Appears radiopaque (white/light) in images, contrasting against surrounding soft tissue for visibility.

  • Can be identified by nodular formations or ledges visible on radiographs, indicating potential areas of concern.

  • Ring-like calcifications could indicate overhangs that lead to calculus retention and need for corrective restoration.

Restoration Assessment in Periodontal Health

• Routine checks for uneven margins, open contacts, and overhangs are critical for maintaining periodontal health.

• Importance of smooth margins to prevent periodontal issues; rough or uneven surfaces harbor plaque and calculus.

• Failure to address these restoration concerns can lead to inflammation and further periodontal disease, necessitating more complex interventions.

Summary of Key Points

• Periodontal assessment involves a synergistic combination of clinical evaluation and radiographic analysis to ensure comprehensive care.

• Understanding the different bone loss patterns is crucial for effective diagnosis and classification, aiding in tailored treatment plans.

• Regular assessments alongside an understanding of local and systemic factors are essential for effective management of periodontal health and preventing disease progression.