Diagnosis Kuretase

diagnosis is the clinician’s belief that the person has the attribute.
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The World Health Organization defined disease as those adverse

health consequences that include physical or psychological impair
ment, activity restrictions, and role limitations.
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Certain periodontal
conditions have been associated with such adverse consequences,
and thus certain periodontal conditions qualify as diseases according
to the WHO’s definition. In one study, about 1 in 5 patients who
presented to a periodontal specialist reported that their teeth, gums,
or dentures had an impact fairly often or very often on either eating;
relaxing; avoiding going out; or feeling self-conscious, pain, or
discomfort. In this same study, 4 out of 10 patients rated their oral
health as fair or poor.
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Other studies have shown that gingival

conditions (e.g., necrotizing ulcerative gingivitis, attachment loss in
high school students) are similarly related to oral health–related
quality of life.
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An important thing to consider during periodontal diagnosis is

to determine which periodontal conditions can be diagnosed as
“diseased.” Can a patient with a couple of sites with 1 or 2 mm of
attachment loss be classified in this way? What about a patient with
such subtle gingival inflammation that the majority of clinicians
would not notice the inflammation and that even highly trained clinical
examiners agree poorly about the presence of gingivitis? Disagreement
regarding such questions is one of the reasons that the prevalence
of gingivitis and destructive periodontal disease can range widely,
depending on which reference levels are considered to be the cutoff
for normal as compared with diseased.
Diagnostic Tests Available to Assess
Periodontal Conditions
Diagnostic tests for periodontal disease can include anatomic measures
of tissue destruction, such as probing pocket depth and clinical
attachment loss; measures of gingival inflammation, such as redness,
suppuration, bleeding, bleeding on probing, elevated gingival
temperature, and gingival crevicular fluid markers; radiographic
measures of bone destruction and tooth mobility; and microbiologic
measures. These test results—in combination with factors such as
age, dental history, and systemic conditions—can be translated into
a distinct set of periodontal diagnoses.
Translating Periodontal Diagnostic Test Results
Into Periodontal Disease Diagnosis
Three different methods can be distinguished to translate clinical
conditions into diseases: (1) normative or arbitrary values, (2) risk
based reference values, and (3) treatment-based reference values.
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Normative or Arbitrary Values to Diagnose

Periodontal Disease
Diseases can be defined on the basis of normative or arbitrary reference
values. If the normal periodontium is assumed to have no pockets
deeper than 3 mm, then one could define destructive periodontal
disease as being present in a patient with any pocket equal to or deeper
than 4 mm, or a patient with three pockets equal to or deeper than
5 mm could be classified as having destructive periodontal disease.
Alternatively, normative values could be based on parametric or
nonparametric percentage cutoff values as derived from national

marker at which a steep increased risk for adverse health outcomes

is present. The cutoff is still somewhat arbitrary, but it is connected
to clinical realities in terms of the risk of adverse health outcomes.
There is a tradeoff between the dangers of missed diagnoses when
the cutoff is made too high (i.e., more specific) and the dangers of
false-positive diagnoses when the cutoff is too low (i.e., more
sensitive).
A risk-based diagnosis of destructive periodontal disease requires
the conducting of longitudinal studies in which pocket depth at
baseline is related to the risk of subsequent adverse outcomes (e.g.,
tooth loss). Fig. 6.1 represents such a plot and suggests that a pocket
depth of 6 mm could be a diagnostic marker for destructive periodontal
disease, because a distinctive increased risk for tooth loss is associated
with pocket depth values of 6 mm or deeper.
The risk-based diagnosis of chronic diseases, much like the use
of normative or arbitrary values, can do more harm than good. A
diagnosis of obesity that is based on a body mass index of 28 may
do more harm than good if weight loss treatments increase mortality
risk.
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A diagnosis of high blood pressure

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or diabetes
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may cause
more harm than good if the prescribed treatment further increases
the mortality risk. Similarly, a diagnosis of destructive periodontal
disease that is based on the presence of periodontal pockets 6 mm
or deeper may cause more harm than good if the suggested periodontal
treatments increase periodontal morbidity.
Periodontal Disease Diagnoses
The Medical Subject Heading (MeSH) term headings for periodontal
disease, the classification systems for periodontal diseases developed
by professional organizations, and a sampling of English-language
periodontal textbooks indicate that periodontal disease diagnoses
come and go at a fast rate. On PubMed, seven different entry terms

reflects some of the distinct periodontal diagnoses that have been

used in the literature since 1965. However, a conference consensus
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concluded that five of the seven terms listed were obsolete. The
American Academy of Periodontology reported 10 different classifica
tion systems in 20 years.
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Periodontal textbooks have similarly reported

different sets of periodontal diagnoses every decade.
Periodontal dystrophies provide one example on the apparent
arbitrariness by which periodontal diagnoses come and go. Periodontal
dystrophies were commonly reported from the 18th century until
the 1960s. However, this diagnosis was subsequently decided to be
obsolete,
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because it did not appear to fit the infection paradigm.

Periodontal textbooks no longer referred to the diagnosis of “peri
odontosis.” However, an argument was made that this diagnosis
should be resurrected.
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This example illustrates how profoundly the belief that periodontal

disease is infectious has influenced all aspects of clinical periodontics,
including the system for classifying periodontal conditions. Periodontal
diagnoses in some circles are based on the premise that periodontal
diseases “follow an infection/host paradigm in which it is held that
noxious materials from dental plaque bacteria induce an inflammatory
response in the adjacent periodontal tissue. … Central to this paradigm
is the notion that the destruction of periodontal tissues is accompanied
by an inflammatory response.”