DIAGNOSIS

DR SHERMIN HASHIR
LECTURER
DEPARTMENT OF
PERIODONTOLOGY
LEARNING OBJECTIVES

1. HOW TO REACH A DIAGNOSIS AND

WHAT ARE THE FACTORS TO BE
CONSIDERED.
2. REVISE DCP 1 LECTURES THOROUGHLY
ON
1. CLINICAL EXAMINATION,
2. HEALTHY AND NORMAL GINGIVA,
3. PERIODONTAL CHARTING
4. AND PROBING, RECESSION, PERIODONTAL
POCKET
5. CLASSIFICATION (2017) BEFORE THIS
LECTURE.
THE PERIODONTAL
DIAGNOSIS IS A
SUMMATION FROM THE
MEDICAL AND DENTAL
HISTORIES COMBINED
WITH FINDINGS OF THE
CLINICAL AND
RADIOGRAPHIC
EXAMINATION.
Periodontal diagnosis is
determined after careful
analysis of the case history and
evaluation of the clinical signs
and symptoms, as well as the
results of various tests (e.g.,
probing, mobility assessment,
radiographs, blood tests, and
biopsies
• Proper diagnosis is essential to intelligent
treatment. Periodontal diagnosis should
• first determine whether disease is present;
• then identify its type,
• severity;
• extent,
• if periodontitis (grading)
• and finally provide an understanding of the
underlying pathologic processes and its cause.
DIAGNOSIS FLOW CHART
CASE HISTORY

•Overall Appraisal of the

Patient.
•This includes consideration of
the patient's mental and
emotional status, attitude,
and physiologic age
 MEDICAL HISTORY

1. To identify systemic factors which may help to account

for the periodontal condition, ex: Pregnancy, Diabetes
Mellitus.
2. To note the existence of systemic condition for which
special precautions (ex. Antibiotic prophylaxis) are
required to safeguard the patient during the periodontal
therapy.
3. To note the presence of any transmissible disease which
may present a hazard to the clinician, dental surgery staff
or other patients
• The health history should include reference to the following:
• 1.PHYSICIAN DETAILS..
• 2. Details regarding hospitalizations and
operations and Complications
• 3. A list of all medications being taken
,possible effects of these medications should
be care fully analyzed to determine their
effect
• 4. All medical problems (e.g., cardiovascular,
hematologic, endocrine), including infectious
diseases, STDS, ALLERGIES, BLEEDING
DISORDERS.
• FEMALE HISTORY- menopause, pregnancy
• History of alcohol, drugs, tobacco-attitudes-
cessation programmes.
 DENTAL HISTORY

• Patients attitude towards Dental health

• Date and nature of last dental treatment
• Regularity of previous dental treatment
• Oral hygiene habits- tooth brush, dental floss
• Habits related to oral health or disease
DENTAL HISTORY- chief complaint
• GINGIVAL BLEEDING-
• Spontaneous- ALERT!!!
• During mastication
• Tooth brushing • Condition of existing
• PAIN Dentures
• Acute periodontal lesions. • Presence of implants to replace
• Dentine hypersensitivity Missing teeth.

• Periapical or pulpal lesions

• Caries
• SWELLING- Abscesses
• TOOTH MOBILITY
• Inflammation
• Bone loss
• Trauma- HABITS, BRUXISM, GRINDING
• BAD BREATH AND TASTE- food impaction,
inflammation
 PHOTOGRAPHS
• An important part of periodontal examination and
diagnosis is the documentation of clinical findings.
• Digital photographic documentation is important
and useful for
• 1. record-keeping,
• 2. education of both the clinician and the patient,
• 3. communication with referrals and colleagues,
• 4. and planning and treatment of high aesthetic demand
cases.
• 5. Photographs can provide details that a clinician may
not otherwise remember
• 6. and allow the clinician to evaluate the mouth after the
patient leaves
• 7. and to monitor changes in the tissue over time
 EXAMINATION AND INVESTIGATIONS
- CLINICAL EXAMINATION OF PERIODONTIUM

 THE PERIODONTAL CHARTING AND RECORDING

SYSTEMS- PSR, PERIODONTAL CHARTS, GINGIVAL
FORMS, BASIC PERIODONTAL EXAMINATION

 LABORATORY AIDS , RADIOGRAPHS TO CLINICAL

DIAGNOSIS
NUTRITIONAL STATUS
-

-PATIENT ON SPECIAL DIET FOR MEDICAL REASONS

-BLOOD TESTS, IMMUNOLOGICAL TESTS.
CLINICAL EXAMINATION
• Oral hygiene. (food debris, calculus,
biofilm, stains)
• Tongue, oral mucosa, vestibule, lips,
floor of the mouth, tongue , palate,
oropharyngeal region- CHECK FOR
ANY PATHOLOGIES OR SWELLINGS
• Examine LYMPH NODES- head, neck
due to malignancies , infections.
 WASTING DISEASES OF TEETH
• Wasting is defined as any gradual loss of tooth
substance characterized by the formation of
smooth, polished surfaces, without regard to the
possible mechanism of this loss. The forms of
wasting are erosion, abrasion, and attrition
• Erosion, also called corrosion, is a sharply
defined wedge-shaped depression in the cervical
area of the facial tooth. Erosion generally affects
a group of teeth. In the early stages, it may be
confined to the enamel, but it generally extends
to involve the underlying dentin, as well as the
cementum.
• The etiology of erosion is not known.
Decalcification by acidic beverages, or citrus
fruits in combination with the effect of acid
salivary secretion are suggested causes.
 ABRASION AND ATTRITION
Abrasion refers to the loss of
tooth substance induced by
mechanical wear other than
that of mastication. Abrasion
results in saucer-shaped or
wedge-shaped indentations
with a smooth, shiny surface.

Attrition is 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.
 EXAMINATION OF PERIODONTIUM

VISUAL EXAMINATION
• Plaque and calculus
• Gingival macroscopic features

TACTILE EXAMINATION
• Probing
Plaque and Calculus.
• There are many methods for
assessing plaque and calculus
accumulation.
• " The presence of supragingival
plaque and calculus can be
directly observed and the
amount measured with a
calibrated probe.
• For the detection of subgingival
calculus, each tooth surface is
carefully checked to the level of
the gingival attachment with a
sharp no. 17 or no. 3A explorer.
• Warm air may be used to deflect the gingiva and aid in visualization
of the calculus.

• Radiograph may sometimes reveal heavy calculus deposits

interproximally and even on the facial and lingual surfaces.

• The gingiva must be dried before accurate observations. Light

reflection from moist gingiva obscures detail. In addition to visual

examination and exploration with instruments
 GINGIVAL VISUAL EXAMINATION
• Each of the following features of the
gingiva should be considered:
 color
 size
 contour
 consistency
 surface texture
 position
 ease of bleeding
 pain
 Firm but gentle palpation should be used
for detecting pathologic alterations in
normal resilience, as well asfor locating
areas of pus formation.
• Gingival inflammation can produce two basic types of
tissue response. The Marginal gingiva is palpated with a
periodontal probe to assess its consistency and adaptation to
the tooth.
• Edematous tissue response is characterized by a smooth, glossy,
soft, red gingiva. edematous, spongy, and loosely adapted to
the tooth surface due to the degradation of collagen and the
influx of cells and fluid into the lamina propria .

• In the fibrotic tissue response, some of the

characteristics of normalcy persist; the gingiva is more
firm, stippled, and opaque, although it is usually
thicker, and its margin appears rounded.
• In cases of chronic inflammation and in smokers, the
gingival tissue may be fibrotic
TACTILE PERIODONTAL EXAMINATION
MARGINAL BLEEDING

• Marginal bleeding is associated with

inflammatory changes in the marginal gingiva.
• Marginal bleeding can be evaluated by running
an instrument such as a probe or rubber tip
along the gingival margin.
• Under pressure, healthy gingival tissue will
blanch and not bleed, whereas in the presence
of gingival inflammation, marginal bleeding may
be observed.
• The ease of marginal bleeding are correlated
with the severity of gingival inflammation.
 SUPPURATION
• Palpation of the marginal gingiva with a probe, or digitally
by placing the ball of the index finger on the gingiva apical
to the margin, and pushing coronally toward the gingival
margin may squeeze a white-yellowish exudate from the
gingival crevice.
• Suppuration does not occur in all periodontal pockets, but
pressure often reveals it in pockets where its presence is
not suspected
• Several studies have evaluated the association between
suppuration and the progression of periodontitis and have
reported that this sign is present in a very low percentage
of diseased sites (i.e., 3% to 5%). Therefore, absence of
suppuration does not indicate absence of disease.
Purulent exudate expressed from a periodontal pocket by digital pressure.
 PERIODONTAL POCKETS

• Examination for periodontal pockets must include

consideration of the following:
• presence and distribution on each tooth surface,
• pocket depth,
• level of attachment on the root and
• type of pocket (suprabony or intrabony).
• Measure the amount of attached gingiva
 Bleeding on
Probing
• The insertion of a probe to the bottom of the pocket elicits bleeding if the gingiva
isinflamed and the pocket epithelium isatrophic or ulcerated.

Non inflamed sites rarely bleed.

• In most cases, bleeding on probing isan earlier sign of inflammation than

gingival colour changes.

• However, sometimes colour changes are found with no bleeding on

probing.
Periodontal pockets around lower anterior teeth, showing rolled margins, edematous
inflammatory changes and abundant calculus
 Signs And Symptoms
• Probing is the only reliable
method of detecting pockets,
but other changes also play
a very important role, such
as:
• Color changes
Bluish-red marginal gingiva
Bluish-red vertical zone
extending from the gingival
margin to the attached gingiva,a
"rolled" edge separating the gingival
margin from the tooth surface
• The presence of bleeding,
suppuration, and loose, extruded
teeth may also denote the
presence of pockets
A) Extrusion of the maxillary left central incisor and diastema
associated with a periodontal pocket
B)Deep periodontal pocket revealed by probing. The probe has
penetrated to its entire length.
 Periodontal pockets are generally
painless but may give rise to
symptoms such as localized or
sometimes radiating pain or
sensation of pressure after eating,
which gradually diminishes.

• There can also be foul taste in

localized areas, sensitivity to
hot and cold, and toothache in
the absence of caries
•Guttapercha points or calibrated silver points 19
can
be used with the radiograph toassist in
determining the level of attachment of
periodontalpockets

Blunted silver points assist in locating the base of pockets

 Gingival recession
• The location of the gingival margin around teeth should be evaluated and
recorded, especially when recession is present. In the absence of attachment
loss, the gingival margin is located coronal to the cementoenamel junction.
• The presence of recession indicates that attachment loss has
occurred, but not necessarily that inflammation is present.

This measurement is taken with a periodontal probe from the cemento-

enamel junction to the gingival crest.
When to probe
• Probing of pockets is done at various times for diagnosis, and for
monitoring the course of treatment andmaintenance.

• The initial probing of moderate or advanced cases is usually hampered

by the presence of heavy inflammation and abundant calculus and
cannot be done very accurately.

Probe penetration can vary depending on:

• the force of introduction,
• the shape and size of the probe tip and
• the degree of tissue inflammation
• The purpose of the initial probing, together with the
clinical and radiographic examination is done, however, with the

main purpose of determining whether the tooth can be saved or

should be extracted.

• After the patient has performed an adequate plaque control for

some time and calculus has been removed, the major inflammatory

changes disappears, and a more accurate probing of the pockets

can be performed.
• This second probing is for the purpose of accurately establishing
the level of attachment and degree of involvement of roots and
furcations.

• Data obtained from this probing provides valuable information for

treatment decisions.

• Further along periodontal treatment probings are done to determine

changes in pocket depth and to ascertain healing progress after
different procedures.
 Amount of attachedgingiva

• It is important to establish the relation between the

bottom of the pocket and the muco-gingival line.

• The width of the attached gingiva is the distance between

the muco- gingival junction and the projection on the
external surface of the bottom of the gingival sulcus or
the periodontal pocket.

• It should not be confused with the width of the keratinized

gingiva,
because the latter also includes the marginal gingiva
 ALVEOLAR BONE LOSS

• Alveolar bone levels are evaluated by clinical and radiographic

examination.
• Probing is helpful for determining
the height and contour of the facial and lingual bones obscured on the
radiograph by the dense roots
 the architecture of the inter-dental bone.

• Trans-gingival probing, performed after the area is anesthetized, is

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

• A periodontal abscess is a localized accumulation of pus within

the gingival wall of a periodontal pocket. Periodontal
abscesses may be acute or chronic.

• The acute periodontal abscess appears as an ovoid elevation

of the gingiva along the lateral aspect of the root.

• The gingiva is edematous and red, with a smooth, shiny

surface. The shape and consistency of the elevated area
vary; the area may be domelike and relatively firm, or pointed
and soft.
MOBILITY
Each tooth should be rocked between an instrument
handle and index finger in a buccolingual direction and
mesiodistal direction (when the adjacent tooth is not
present).
 OTHER FINDINGS
1. OCCLUSION- DEEP BITE, OVER JET, OVERBITE
• The occlusion should be examined for detect
premature or interfering contacts as contributory
factors.
• • Vertical bone destructive pattern is often associated
with traumatic occlusion.

1. FURCATION LESIONS
2. TOOTH MIGRATION
 PERIODONTAL
PERIODONTAL CHARTINGCHARTING

Adding a New Perio Chart

•
PROBING DEPTH V/S CLINICAL ATTACHMENT
LEVEL(important parameters for diagnosis)

• Next class Dr. Abier will discuss in detail.

• 1. Pocket depth: (PPD—probing pocket depth) Distance measured from
the tip of the probe (located at the apex of the gingival sulcus) to the gingival
margin. Inflamed tissues are much looser than the healthy ones.
Consequently the probe penetrates more deeply with respect to the actual
depth of the periodontal pocket (clinical parameter). Probing performed
before the causal therapy will present greater depths than is actually the
case; the bottom of the pocket is not a reference point for assessing the loss
of periodontal attachment (histologic parameter).
• 2. Attachment level: (PAL—probing attachment level) Distance between
the cemento-enamel junction and the lowermost point of the gingival sulcus.
It is clear that attachment level and pocket depth will exhibit identical values
when the gingival margin and cemento-enamel junction correspond.
Patients on Special Diets for Medical
Reasons
• Patients on low-residue, non detergent diets often develop
gingivitis because the prescribed foods lack cleansing action
and the tendency for plaque and food debris to accumulate on
the teeth is increased.

• Because fibrous foods are contraindicated, special effort is

made to compensate for the soft diet by emphasizing the
patient's oral hygiene procedures.
• Patients on salt-free diets should not be given saline mouthwashes,

nor should they be treated with saline preparations without

consulting their physician.

• Diabetes, gallbladder disease, and hypertension are examples of

conditions in which particular care should be taken to avoid the

prescription of contraindicated food.
 Blood tests
• Analyses of blood smears, red and white
blood cell counts, white blood cell
differential counts, and erythrocyte
sedimentation rates are used to evaluate
the presence of blood dyscrasias and
generalized infections.

• Determination of coagulation time,

bleeding time, clot retraction time,
prothrombin time, capillary fragility test,
and bone marrow studies may be
required at times.

• They may be useful aids in the differential

diagnosis of certain types of periodontal
diseases.
 INVESTIGATIVE RADIOGRAPHS

Panoramic radiographs are a simple and convenient method of

obtaining a survey view of the dental arch and surrounding structures.
They are helpful for the detection of developmental anomalies,
pathologic lesions of the teeth and jaws, and fractures as well as
dental screening examinations of large groups. They provide an
informative overall radiographic picture of the distribution and
severity of bone destruction in periodontal disease, but a complete
intraoral series is required for periodontal diagnosis and treatment
planning
A full mouth intraoral radiographic series(17 periapical films and
4 bitewing
•
Diagnosis list from 2017
CLASSIFICATION
First decide which disease or condition is present (may be more than one disease
or condition present)
Use main classification categories and sub-classifications (2017-NEW
CLASSIFICATIONS)
If any uncertainty, list differential diagnoses i.e. other possible diagnoses, ranked
from the most to the least likely
Provides other options if initial diagnosis proves to be incorrect
Then describe severity & Complexity
Designate -STAGING AND GRADING
e.g. for gingivitis, comment on degree of gingival redness, swelling, bleeding
Then state whether disease is localised or generalised
e.g. for Periodontitis, Localised is where ≤ 30% sites involved, Generalised >
30% sites
Can specify precise location and sites.
Flow towards treatment plan

 Examination → Diagnosis → Prognosis ↔ Treatment

 • Diagnosis requires thorough and careful examination.
 • Prognosis is based on accurate diagnosis.
 • Treatment decisions are based on prognosis.
 • Treatment decisions are made to improveprognosis
EXAMPLES OF DIAGNOSES

• Generalised gingivitis

• Localised gingivitis

• Necrotising periodontitis

• Generalised gingivitis with localized periodontitis(stage&grade).

• Generalised periodontitis(stage &grade)

• CONCLUSION

• The establishment for a diagnosis is a prime requisite for an ideal

treatment protocol , and this is the success of a practitioner to have

an ideal power of observation and clinical examination to reach this

conclusion.
References

• CARRANZA’S- CLINICAL PERIODONTOLOGY

-12th edition, 13th edition
• SOBEN PETER-Community and Preventive Dentistry