1 Lec Examination and Diagnosis 2

CLINICAL PERIODONTICS
Examination and Diagnosis

Dr. Handren Hunar Najeeb
1st lec 5th grade
2020-2021
Periodontal Examination and Diagnosis
1. Overall Appraisal of the Patient.
2. Health History.
3. Dental History.
4. Photographic Documentation.
5. Clinical Examination.
6. Tactile periodontal examination.
7. Examination of the Teeth and Implants.
8. Radiographic Examination.
9. Laboratory Aids to Clinical Diagnosis.
10. Periodontal Diagnosis.
11. Assessment of Biofilm Control and Patient Education.
1.Overall Appraisal of the Patient
• includes consideration of the patient’s :
–Mental and emotional status,
–Temperament,
–Attitude,
–Physiologic age.
2.Health History
• Inform patient
• The patient should be made aware of the following:
1. The possible impact of certain systemic diseases, conditions, behavioral
factors, and medications on periodontal disease, its treatment, and
treatment outcomes.
2. The presence of conditions that may require special precautions or
modifications of the treatment procedure, (Cardiovascular Diseases ,
Endocrine Disorders, Hemorrhagic Disorders, Medications and Cancer
Therapies… etc)
3. The possibility that oral infections may have a powerful influence on the
occurrence and severity of a variety of systemic diseases and conditions
2.Health History
• Inform dentist ( yourself)
• The health history should include reference to the
following:
1. The date of the last physical exam and the frequency of
physical exams and physician visits. If the patient is under
the care of a physician, the nature and duration of the
problem and its therapy should be discussed.
2. All medical problems (e.g., cardiovascular, hematologic,
endocrine), including infectious diseases.
2.Health History
3. Abnormal bleeding tendencies, such as nosebleeds,
prolonged bleeding from minor cuts, spontaneous
ecchymosis, a tendency toward excessive bruising, and
excessive menstrual bleeding, should be cited.
4. A list of all medications being taken,
– Patients who are taking any of the family of drugs called
bisphosphonates (e.g., Actonel, Fosamax, Boniva, Aredia,
Zometa), which are often prescribed for osteoporosis, should be
cautioned about possible problems related to osteonecrosis of the
jaw after undergoing any form of oral surgery involving bone.
– Allergy history to medications also should be taken.
3.Dental History
• Chief Complaint and Current Illness
– Some patients may be unaware of any problems.
– Many may report bleeding gums, loose teeth, spreading of the teeth
with the appearance of spaces where none existed before, foul taste in
the mouth, or an itchy feeling in the gums that is relieved by digging with
a toothpick.
– There may also be pain of varied types and duration, including constant,
dull, gnawing pain; dull pain after eating; deep radiating pain in the jaws;
acute throbbing pain; sensitivity when chewing; sensitivity to hot and
cold; burning sensation in the gums; or extreme sensitivity to inhaled air.
3.Dental History
• The dental history should include reference to the following:
1. Visits to the dentist.
2. The patient’s oral hygiene regimen should be described,
including toothbrushing frequency, time of day, method,
type of toothbrush and dentifrice, mouthwashes, interdental
brushes, other devices, water irrigation, and dental floss.
3. Any orthodontic treatment, including its duration and the
approximate date of termination, should be noted.
3.Dental History
4. If the patient is experiencing pain in the teeth or in the
gingiva, the manner in which the pain is provoked, its
nature and duration, and the manner in which it is
relieved should be described.
5. Note the presence of any gingival bleeding, including
when it first occurred; whether it occurs spontaneously,
on brushing or eating, at night, or with regular periodicity;
whether it is associated with the menstrual period or
other specific factors.
3.Dental History
6. A bad taste in the mouth and areas of food impaction should be
mentioned.
7. Assess whether the patient’s teeth feel “loose” or insecure, if he
or she has any difficulty chewing, and whether there is any
tooth mobility.
8. Note the patient’s general dental habits, such as grinding or
clenching of the teeth during the day or at night. Do the teeth
or jaw muscles feel “sore” in the morning? Are there other
habits to address, such as tobacco smoking or chewing, nail
biting, or biting on foreign objects?
4.Photographic Documentation
• Initial photographs should be taken before the tissue is
probed and manipulated to obtain an undisturbed baseline
of the patient’s mouth with gingiva and biofilm intact.
• Color photographs are useful for recording the appearance
of the tissue before and after treatment.
• At minimum, an initial set of photographs for a periodontal
patient contains nine images.
The retracted frontal
Image is a direct shot
The remaining eight

images are mirror shots.
An image capturing
the palatal surfaces
of the anterior
maxilla is presented
on a 27-inch
computer screen to
help a patient
understand her
periodontal disease.
5.Clinical Examination
A. Examination of Extra oral Structures
– Evaluation of the extraoral structures for
abnormalities.
– The temporomandibular joints should be assessed.
– Muscles of mastication should be palpated.
– lymph nodes of the head and neck.
B. Examination of the Oral Cavity
– Beginning with oral hygiene, the extent of accumulated food debris,
biofilm, calculus, and tooth surface stains, as well as biofilm coating of
the dorsum of the tongue.
– Oral malodor (halitosis).
– The lips, the floor of the mouth, the tongue, the palate, the vestibule,
and the oropharyngeal region should be evaluated for abnormalities and
pathologies.
– The oral mucosa in the lateral and apical areas of the tooth may be
palpated for tenderness to detect periapical and periodontal abscesses.
A biofilm coating of the dorsum surface of the tongue (A) can be a source of oral
malodor. When the tongue is heavily coated, the biofilm may need to be scraped
off with a spatula (B and C).
C. Examination of the Periodontium
– Should be systematic
– Should not immediately begin with insertion of the periodontal probe into the
gingival crevice.#
– Should begin with a thorough and careful visual evaluation of the gingival margin
to assess biofilm and calculus accumulation as well as inflammatory changes in
the soft tissue.
its consists of three parts:
 Visual Periodontal Examination
 Visual Examination of Biofilm and Calculus
 Visual Examination of the Gingiva
– After visual evaluation, the gingiva, the gingival crevice, and the subgingival tooth
surface are carefully probed.
 Visual Periodontal Examination
– Begins with drying the tissue and taking a survey of biofilm and
calculus accumulation to assess oral hygiene as well as clinical
signs of inflammation (erythema, edema, etc.) and recession to
assess the presence and severity of disease.
 Visual Examination of Biofilm and Calculus
– Biofilm frequently accumulates in concavities along the gingival margins
and in embrasure spaces, especially in difficult-to-reach places, such as
the distal surface of the distal-most tooth in the quadrant and the lingual
surfaces of the mandibular molars.
– Supragingival calculus commonly accumulates on the lingual surfaces of
the mandibular anterior teeth and the buccal surfaces of the maxillary
molars due to the presence of the respective Wharton and Stensen
salivary ducts and ineffective biofilm removal.
– The presence of biofilm on the buccal and facial surfaces of teeth closest
to the midline may suggest inadequate oral hygiene.#
• Biofilm frequently
accumulates on tooth
surfaces in concavities
along the gingival
margin and inter
proximal spaces.
 Visual Examination of the Gingiva
– Evaluation of the gingiva requires the tissue to be dried before accurate
observations can be made.
– Generally, healthy gingiva is coral pink or salmon pink in color, gingival contour
consists of sharp, thin, knife-edge margins with scalloped gingival architecture and
sharp papillae. The surface texture of healthy gingiva is matte and stippled.#
– In the presence of inflammatory periodontal disease, the color of the gingiva may
be erythematous or cyanotic, inflamed gingiva may have rolled margins and
bulbous papillae. The surface texture in the presence of inflammation may be
smooth and shiny, and the gingiva may appear swollen and edematous.
– The location of the gingival margin around teeth should be evaluated and
recorded, especially when recession is present.
A B
Saliva obscures details.
(A) The gingiva appears smooth when covered in saliva.
(B) Once dried, stippling is visible, and erythema and edema become more obvious.
clinical findings of healthy and inflamed gingiva
6.Tactile Periodontal Examination
• By using periodontal probe it begins with:
– The evaluation of the consistency of the gingiva.
– Its adaptation to the tooth.
– The presence of marginal bleeding.
– Suppuration.
• The gingival crevice is then probed to evaluate the subgingival
environment.
• The tooth surface is carefully probed for (aberrations, concavities,
furcation, and subgingival calculus).
 Tactile Examination of the Marginal Gingiva
– A periodontal probe used to assess its consistency and adaptation to the tooth.
– Healthy gingiva is firm, resilient, and well adapted to the tooth, (due to the
presence of dense collagen fiber bundles in the lamina propria of the
gingiva).
– Inflamed gingiva is 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 cases of chronic inflammation and in smokers, the gingival tissue may be
fibrotic.
The severely inflamed gingiva is loosely adapted to the tooth. The

marginal gingiva is easily retracted to reveal heavy subgingival biofilm
and calculus.
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,
– Inflamed gingival tissue , marginal bleeding may be observed.
Suppuration:
• Palpation of the marginal gingiva 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.
Suppuration
Purulent exudate
expressed from a
periodontal pocket
by digital pressure.
• Tactile Examination of the Gingival Crevice
– The probe is inserted into the gingival crevice vertically with
the tip of the probe touching and sliding down along the
tooth surface to the bottom of the crevice.
– The probe is “walked” circumferentially around each surface
of each tooth to detect the areas of deepest penetration.
Probing Around Implants
• A traditional periodontal probe may be used under light
force without damaging the peri-implant mucosal seal.
• The probing depth around
implants presumed to be
healthy (and without
bleeding) has been
documented as about 3
mm around all surfaces.
Probing Depth
• Is the distance from the
gingival margin to the
bottom of the probeable
crevice (i.e., where the
probe tip stops).
Periodontal Pockets.
– Examination for periodontal pockets must include their:
1. Presence and distribution on each tooth surface.
2. Pocket depth.
3. Level of attachment on the root.
4. Type of pocket (suprabony or infrabony).
• There are two different pocket depths:
1. The biologic or histologic depth.
• This can be measured only in histologic sections.
2. The clinical or probing depth.
• Measured by periodontal probe.
• Probing depth is generally ≤3 mm in gingival health and >3 mm

in the presence of gingival inflammation.
Attachment Loss
• Is the apical migration of the dentogingival junction—the
periodontal attachment apparatus—as a result of the inflammatory
response.
• The dentogingival junction consists of the epithelial attachment
and the connective tissue attachment.
• The dimension of the dentogingival junction is called the biologic
width and averages 2.04 mm.
• Clinical Attachment Loss ( CAL )
– The distance from the cementoenamel junction to the bottom of the
probeable crevice.
– When the gingival margin is located on the anatomic crown, clinical
attachment loss is determined by subtracting the distance from the
gingival margin to the cementoenamel junction from the probing depth.
– When the gingival margin is located apical to the cementoenamel
junction, clinical attachment loss is the sum of gingival recession and
probing depth.
Use of Clinical Indices in Dental Practice
• Gingival Index
0 = Normal gingiva (clinically).
1 = Mild inflammation, slight change in color slight edema , no
bleeding on probing.
2 = Moderate inflammation redness, edema glazing, bleeding
on probing after (30-60 sec).
3 = Severe inflammation, marked redness and edema,
ulceration and spontaneous bleeding.
• Plaque Index
0 = No plaque
1 = Thin film of plaque at the free gingival margin (FGM) area
of the tooth not seen by naked eye detected by a probe .
2 = Moderate accumulation of soft deposit on the gingival area
of the tooth can be seen by naked eyes .
3 = Abundance of soft deposit clearly fill the interdental papilla.
7.Examination of the Teeth and Implants
A. Wasting Disease of the Teeth
B. Dental Stains
C. Hypersensitivity
D. Proximal Contact Relations
E. Tooth Mobility
F. Trauma From Occlusion
G. Pathologic Migration of the Teeth
H. Sensitivity to Percussion
I. Dentition With the Jaws Closed
J. Functional Occlusal Relationships
A. Wasting Disease of the Teeth
Defined as any gradual loss of tooth substance, which is
characterized by the formation of smooth, polished surfaces
without regard to the possible mechanism of this loss.
• Wasting Disease includes:
– Erosion: caused by acid beverage, Citric fruits, acidic salivary secretion ( chemical
causes ).
– Abrasion: smooth shiny wear defect surface due to continued exposure to abrasive
material , tooth brush with highly abrasive dentifrices and action of clasps of
removable partial denture ( external mechanical force).
– Attrition: occlusal wear result from functional contact with opposing teeth .
– Abfraction: cervical wear at the area above the marginal bone due to excessive oral
forces exerted on the tooth cusp, this will lead to compression and tension at the
cervical area lead to damage of tooth Structure at this area
B. Dental Stains
– Dental stains are pigmented deposits on the teeth.
– Stains are primarily an aesthetic problem and do not cause
inflammation of the gingiva.
– Tobacco products, coffee, tea, certain
mouthrinses, and pigments in foods
can contribute to stain formation.
C. Hypersensitivity
• Exposed root surface due to gingival
recession may be hypersensitive to
thermal changes or tactile sensation
they may be located by gentle probing
or cold air .
• Also caused by Wasting Disease of the
Teeth.
D. Proximal Contact Relations
– Open contacts allow for food impaction.
– Abnormal contact relationships may also initiate occlusal changes,
such as a shift in the median line between the central incisors
with labial flaring of the maxillary canine, buccal or lingual
displacement of the posterior teeth.
E. Tooth Mobility
Normally all teeth have slight degree of mobility , vary from one
person to another, from one tooth to another and with same person
vary during day time.
Physiologic tooth mobility:
Is movement up to 0.2 mm horizontally and 0.02 mm axially.
Abnormal or pathologic tooth mobility:
Is mobility beyond the physiologic range
Mobility is graded clinically by holding the tooth firmly
between the handles of two metallic instruments or
with one metallic instrument and one finger.
 Mobility grade 1: first distinguishable sign of movement
greater than “normal”.
 Mobility grade 2: movement of the crown up to 1 mm in
any direction.
 Mobility grade 3: movement of the crown more than 1
mm in any direction or vertical depression or rotation of
the crown in its socket.
• Increased mobility is caused by one or more of the
following factors:
1. Loss of tooth support (bone lose).
2. Trauma from occlusion .
3. Extension of inflammation .
4. Periodontal surgery.
5. Pregnancy.
6. Pathologic processes of the jaw.
F. Trauma From Occlusion
• Periodontal findings that suggest the presence of trauma from
occlusion include:
– Excessive tooth mobility.
– Teeth that show radiographic evidence of a widened periodontal space.
– Vertical or angular bone destruction.
– Infrabony pockets.
– Pathologic migration.
G. Pathologic Migration of the Teeth
• Premature tooth contacts in the posterior region that deflect the mandible
anteriorly contribute to the destruction of the periodontium of the maxillary
anterior teeth and to pathologic migration. This is due to the increased trauma
that the mandibular anterior dentition places against the palatal surface of the
maxillary anterior dentition.
H. Sensitivity to Percussion
– Is a feature of acute inflammation of the periodontal ligament.
– Gentle percussion of a tooth at different angles to the long axis
often helps with the localization of the site of inflammatory
involvement.
I. Dentition With the Jaws Closed
• Can detect conditions such as:
– Irregularly aligned teeth.
– Extruded teeth.
– Improper proximal contacts.
– Areas of food impaction.
– Excessive overbite.
– Open-bite relationships.
– Crossbite.
J. Functional Occlusal Relationships
8.Radiographic Examination
1. 14 Periapical films.
2. 4 Bitwing films.
3. 1 panoramic radiograph
• The advantages of radiograph are :

1. To show the height of the remaining
alveolar bone.
2. To give us a survey view of dental
arch and surrounding structures.
3. To help in detection of developmental anomalies, pathologic lesion, fracture
jaw, hidden proximal caries, impacted teeth.
9.Laboratory Aids to Clinical Diagnosis
• When unusual gingival or periodontal problems are detected
that cannot be explained by local causes, the possibility of
contributing systemic factors must be explored.
• Analyses like:
– blood smears, blood cell counts, white blood cell differential
counts, and erythrocyte sedimentation rates, coagulation time,
bleeding time, clot retraction time, prothrombin time, and capillary
fragility as well as bone marrow studies
10.Periodontal Diagnosis
• Three basic diagnostic questions to derive the periodontal
diagnosis:
1. What is the disease?
2. How severe is the disease?
3. What is the extent of the disease?
• Diseases that can affect the periodontium are listed in the
Classification of Periodontal Diseases
• Severity of periodontal disease is classified based on a
three-tier system:
– Slight, mild, early, or initial;
– Moderate.
– Severe or advanced.
• The extent of the disease is classified as:
– Generalized.
– Localized.
• Biofilm-induced inflammatory periodontal diseases are
diagnosed based on the presence of inflammation and
attachment loss
• the severity of chronic periodontitis is characterized on a
three-tier system based on clinical attachment loss (CAL):
1. slight = 1 or 2 mm CAL,
2. moderate = 3 or 4 mm CAL,
3. severe ≥5 mm CAL.
11.Assessment of Biofilm Control and
Patient Education
• It is not uncommon for patients to report brushing and flossing multiple times
daily, while having poorly controlled periodontal disease in their mouths.
• The patient should be asked to demonstrate biofilm control (toothbrushing,
flossing, etc.,) in front of a mirror so that both the patient and the clinician can
see his or her oral hygiene techniques.
• Ideally, unless emergency treatment is required, patients should be given at least
1 or 2 weeks to improve their oral hygiene, to control biofilm and reduce
periodontal inflammation, and to appreciate how they can impact their oral
health with meticulous biofilm control before any periodontal treatment is
rendered.
Thank you ……..

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CLINICAL PERIODONTICS

Examination and Diagnosis

The remaining eight

The severely inflamed gingiva is loosely adapted to the tooth. The

• Probing depth is generally ≤3 mm in gingival health and >3 mm

• The advantages of radiograph are :

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