perio

1. The Periodontal
Examination and Diagnosis

2. Periodontal Examination
Objectives:
Identify the pathological changes of the periodontal
tissues
Describe the above in professional jargon.
Accurately collect/chart following clinical data:
» Probing depth.
» Bleeding on probing points/Suppuration
» Furcation involvements.
» Tooth mobility/ fremitus.
» Gingival recession.
» Mucogingival defects.
» Plaque score.
Analyze the clinical data and develop an overall
diagnosis for the patient.

3. Periodontal Examination
Review of medical/dental
history.
Gingival Examination.
Probing Depth (PD).
Clinical Attachment Level (CAL).
Bleeding upon Probing (BOP).
Mobility Assessment/fremitus.
Furcation Assessment

4. Periodontal Examination (cont.)
Occlusal Assessment
Mucogingival Assessment
Radiographs
Tooth vitality
Etiologic/risk factors

5. Periodontal Examination
Gingival Examination.
– Evaluate tissue changes in terms of:
»Color.
»Consistency.
»Contour.

6. Healthy vs. Diseased Tissues
Normal Diseased
Color Pale pink ±
pigmentation
Acute: Red
Chronic:
bluish pink
bluish red
(cyanotic)
contour Marginal gingiva Knife-
edge margin ±
stippling
Follows a curved line
about the tooth.
Marginal gingiva:
Rounded
Rolled
bulbous

7. Healthy vs. Diseased Tissues
Normal Diseased
Contour
(Cont.)
Papillae:
(1)Normal contact,
papilla is pointed
and pyramidal, fills
the interproximal
area.
(2)Space(diastema):
flat or saddle -shape
Papillae:
Bulbous
Flattened
blunted
Cratered
Consistency Firm, resilient Edematous
Fibrotic

8. Periodontal Examination
Normal Healthy Gingival Unit

9. Periodontal Examination
Diseased Periodontium
Inflamed Gingival Unit -
Changes in Color, Contour
and Consistency
Inflamed Interdental Papillae
and Rolled Gingival Margins

10. Periodontal Examination
Gingival Indices
Used for evaluation and quantitation of
gingivitis.
Used for epidemiological studies.

11. Periodontal Examination
Gingival Indices: (cont’)
Gingival Index (GI) (Loe & Silness 1963).
Papilla Bleeding Index (PBI) (Saxter &
Muhleman 1975).
Gingival Index Simplified(GI-S) (Lindhe
1983) which corresponds to Gingival
Bleeding Index (GBI) (Ainamo&Bay 1975).

12. Periodontal Examination
Gingival Indices: (cont’)
Gingival Index (GI) (Loe & Silness):
- Widely used in epidemiological studies.
- Scores gingival inflammation from 0-3 on
the facial, lingual and mesial surfaces of all
teeth.

13. Gingival Index (GI)
(Loe & Silness)
Grade
0
Normal gingiva, no inflammation,
No discoloration, no bleeding.
1
Mild inflammation, Slight color change,
mild alteration of gingival surface, no
bleeding.
2
Moderate inflammation, erythema,
swelling, bleeding on probing or when
pressure applied.
3
Severe inflammation, severe erythema
and swelling, tendency toward
spontaneous hemorrhage, some
ulceration.

14. Periodontal Examination
Review of medical/dental
history.
Gingival Examination.
Probing Depth (PD).
Clinical Attachment Level (CAL
Mobility Assessment/fremitus.
Occlusal Assessment
Furcation Assessment

15. Periodontal Pocket
Intact Periodontal Pocket Red area indicates
Remaining attachment

16. Red area indicates
Remaining attachment

17. Periodontal Examination
Probing Depth:
The distance from the soft tissue
(gingiva or alveolar mucosa)
margin to the tip of the
periodontal probe during usual
periodontal diagnostic probing.
the health of attachment can
affect the measurement.

18. Periodontal Examination
Probing
Correct Angulation of Probe

19. Periodontal Examination
Information from probing:
Pocket depth/probing depth
Bleeding on probing
Attachment loss
Root deposits
Furcation involvement
Anatomy of the root
Configuration of the pocket
Bone sounding/configuration
of the bony defects

20. Periodontal pocket
AA
A B C
A: gingival pocket.
B: suprabony
pocket.
C: intrabony pocket

21. Periodontal pocket
A B C
A: simple pocket.
B: compound pocket.
C: complex pocket.

22. Periodontal Examination
Factors Affecting Probing Depth
Inflammation.
Presence of subgingival calculus.
Angulation of probe.
Probing force.
Probe tip diameter.
Patient comfort and tolerance.

23. Periodontal Examination
Probing
Over-probing in Inflamed Tissue

24. Periodontal Examination
Probing
Under-probing in Healthy Tissue

25. Periodontal Examination
Constant force probe:
This probe is said to deliver
a known force (20g).
The 20g is delivered when the
the two part of the probe
meet.
(Pro-Dentec, Batesville, AR)

26. Periodontal Examination
Clinical Attachment level
Definition:
the distance from CEJ to the
tip of a periodontal probe
during usual periodontal
diagnostic probing. The
health of Attachment
apparatus can affect The
measurement.

27. Periodontal Examination
Clinical Attachment level
Measuring Clinical Attachment Level

28. Periodontal Examination
Bleeding on Probing (BOP)
Objective sign of gingival
Inflammation.

29. Periodontal Examination
Bleeding on Probing (BOP)
Causes of BOP:
- Gingival inflammation.
- Multiple repeated probe
insertion at a single site.
- Excessive probing force.
- Probing force >0.25N results
in BOP in healthy sites.

30. Periodontal Examination
Bleeding on Probing (BOP)
Clinical significance:
- At a single examination,
presence BOP from a site is not
strongly related to progression of
Periodontitis.
- In treated patients on recall
program continual absence of
BOP is an excellent predictor of
periodontal stability.

31. Periodontal Examination
Bleeding on Probing (BOP)
Clinical significance: (cont.)
In patients on recall/maintenance
program, sites that exhibit BOP on
consecutive visits are at a threefold
greater risk for progression than
sites that only occasionally bleed.

32. Periodontal Examination
Bleeding on Probing(BOP)
It is expressed as a %of number of
bleeding sites divided by the total
number of sites.

33. Periodontal Examination
Tooth Mobility
Causes of mobility:
Trauma from occlusion.
Inflammation.
Loss of support.
Non-periodontal causes.

34. Periodontal Examination
Scale for Mobility Assessment
Grade I Slight Up to 1 mm
Grade II Moderate Between
1-2mm
Grade III Advanced Over 2 mm
and Tooth
depressible

35. Periodontal Examination
Fremitus
Palpable or visible
movement of a tooth when
subjected to occlusal
forces.
Associated with increase
bone and attachment loss.

36. Periodontal Examination
Fremitus
Place index finger on labial
Surface of maxillary teeth.
Ask the patient to grind in
lateral and protrusive
Movement.
Any movement seen or felt
is termed fremitus.

37. Periodontal Examination
Furcation Assessment
How do you evaluate
and diagnose furcation
Involvement?
Probing
Radiographs Color Atlas of Periodontology

38. Periodontal Examination
Furcation Assessment
Furcation Classification:
Hamp et al.1975
– Grade I: horizontal penetration
< 3mm
– Grade II: horizontal penetration
> 3mm but not through and
through.
– Grade III: through and through

39. Periodontal Examination
Furcation Assessment
What is the prevalence of furcation involvement?
In periodontal patients > 40 years old, all second
molars had furcation involvement. Svardstrom & Wennström
1996
Maxillary molars > mandibular molars Svardstrom &
Wennström 1996
Highest frequency of involvement, U6 Distal
Svardstrom & Wennström 1996
Greater severity of furcation involvement in
smokers Kerdvongbundit & Wikesjo 2000

40. Periodontal Examination
Furcation Assessment
Etiology of furcation invasion:
- Extension of inflammatory
periodontal disease.
- Pulpal disease.
- Defective plaque retentive
restorations.
- Anatomical variations:
Enamel pearl.
Cervical enamel projections.
Existence of accessory
pulpal canals.

41. Periodontal Examination
Furcation Assessment
What is the Prevalence of CEPs?
Masters & Hoskins 1964
– 29% of mandibular & 17% of
maxillary molars
– mostly found in buccal furcations
Grewe & Meshkin 1965
 20% L7 > U7 > L6 > U6.
Lieb et al. 1965
 25% mandibular & 22% maxillary
molars
Hou & Tsai 1987
 45% of molars; L6 > U6 > L7 > U7
>L8 > U8
Cervical Enamel projections

42. Periodontal Examination
Furcation Assessment
Cervical Enamel Pearl:
– Incidence: 1.1%-9.7% (mean 2.69
%).
– Predilection for maxillary third
and second molars.
Moskow and Canut 1990

43. Periodontal Examination
Mucogingival Assessment
Includes:
- Marginal tissue recession.
- Inadequate attached gingiva.
- High frenum.

44. Periodontal Examination
Muccogingival Assessment
Mucogingival problem:
Mrginal tissue recession
high frenum
inadequate attached gingiva.

45. Periodontal Examination
Muccogingival Assessment
Marginal tissue recession and
lack of keratinized gingiva on
Mandibular anterior teeth.

47. Miller’s Classification of
Marginal Tissue Recession
Miller PD : Int. J. Periodont Restor Dent 1985; 5: 9.

52. Periodontal Examination
Muccogingival Assessment
Measuring the width of Attached gingiva

53. Periodontal Examination
Muccogingival Assessment
Site with inadequate
Attached gingiva (arrow)

54. Periodontal Examination
Muccogingival Assessment
Multiple frenum associated
With:
- Inadequate attached
gingiva.
- Gingival recession.
- Inadequate oral hygiene

55. Periodontal Examination
Mucogingival Assessment
High frenum

56. Periodontal Examination
Occlusal Trauma
An injury to the periodontal ligament and
alveolar bone as a result of excessive
forces.
There are 2 types of occlusal trauma:
Primary
Secondary

57. Periodontal Examination
Occlusal Trauma
Primary occlusal trauma
results from excessive
occlusal forces applied to a
tooth with normal support.
Note that the center of
rotation is near the middle
of the root.
(From: T. G. Wilson Jr. et al. Advances in periodontics,
1992. Printed with permission, Quintessence
Publishing Co., Inc.).

58. Periodontal Examination
Occlusal Trauma
Secondary occlusal trauma:
results from excessive/normal
occlusal forces applied to a tooth
with reduced periodontium..

59. Periodontal Examination
Occlusal Trauma
Clinical indicators of occlusal trauma:
– Mobility (progressive)
– Fremitus
– Premature occlusal contacts.
– Wear facets in presence of other clinical indicators.
– Tooth migration.
– Fractured tooth
– Thermal sensitivity.

60. Periodontal Examination
Occlusal Trauma
Radiographic indicators of occlusal trauma :
Widened PDL.
Bone loss.
Root resorption.

61. Periodontal Examination
Radiographic Assessment
PeriodontitisHealthy Periodontium

62. Periodontal Examination
Radiographic Assessment
Bone Loss
Horizontal
Vertical
Endodontic involvement
Root deposits
Root anatomy
Root length

63. Periodontal Examination
Radiographic Assessment

64. Periodontal Examination
Radiographic Assessment

65. three-wall vertical defect
two-wall vertical defect
one-wall vertical defect

66. Periodontal Examination
Plaque Control Record
O’Leary et al. 1972
Advantages:
- Gives the dentist, hygienist a simple
method of recording plaque on individual
tooth surface
- Establishes an oral hygiene a baseline.
- Patient education.
- Requires a short time to perform.

67. Periodontal Examination
Plaque Control Record
O’Leary et al. 1972
Disclosing tablets
Disclosed plaque

68. Periodontal Examination
Plaque Control Record
O’Leary et al. 1972
Plaque Score (%):
Number of surfaces with plaque X 100
___________________________________
Number of teeth X 4

69. Periodontal Examination
Plaque Control Record
Factors that hinder patient’s plaque control:
Calculus.
Poor restoration margins.
Over-contoured restorations.
Removable partial appliances.

70. Plaque Index (PI)
(Silness & Loe)
Concerns thickness of plaque along
gingival margin.
Used in epidemiological studies.along
with Gingival index.
Time consuming.
Less useful for routine charting.

71. Plaque Index (Sliness &Loe)
Scores Criteria
0 No plaque
1 A film of plaque adhering to the free gingival margin and adjacent area of
the tooth. The plaque may be seen in situ only after application of
disclosing solution or by using the probe on the tooth surface.
2 Moderate accumulation of soft deposit s within the gingival pocket, or the
tooth and gingival margin which can be seen with the naked eye.
3 Abundance of soft matter within the gingival pocket and/or on the tooth
and gingival margin.

72. Thanks
Any Questions