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Periodontology ­ 1st lecture

26\9\2010

History ,Examination and Periodontal Charting

Revision : What are the components of a healthy periodontium ??? PDL CEMENTUM ALVEOLAR BONE GINGIVA

What are the characteristics of a healthy periodontium ??

- Gingiva : pink, firm gingiva Knife edge gingival margins No redness or edema .

- PDL : intact periodontal ligament No attachment loss (no pocketing).

- cementum : should cover the root surface with inserting sharpey's fibers (functional and healthy and not reduced).

- alveolar bone : no alveolar bone loss

- The normal level of the alveolar bone crest is 0.75 - 1.49 mm below the cemento-enamel junction, so any measurements beyond that ,it is considered an alveolar bone loss .

Classifications of periodontal diseases :

1) gingival diseases : - Plaque induced gingival disease - Non plaque induced gingival disease 2) chronic periodontitis : localized or generalized 3) aggressive periodontitis : localized or generalized 4) periodontitis as a manifestation of systemic disease 5) necrotizing periodontal disease 6) abscesses of the peridontium 7) periodontitis associated with endodontic lesions 8) development or acquired deformities and conditions : - localized tooth related factors - mucogingival deformities around teeth - mucogingival deformities on edentulous ridges - occlusal trauma .

- we have to be able to diagnose all of these conditions even if some of them weren't very common ,and after that either we manage it or refer the patient to a specialist .

History ,Examination and Periodontal Charting :

1) History taking : 1) personal data : name ,age ,occupation 2) presenting complaint : there is a wide range of presenting complaint ,and the patient might come to your clinic complaining of something totally not related to the periodontology .so you as a GP ,you have to manage that case . 3) history of presenting complaint : we need to ask the patient about the details of the presenting complaint ,to help you in diagnosing the problem

For ex : if it was pain ,we ask about : - the onset of the pain - is it continuous or intermittent - spontaneous or provoked - what are the aggravating factors and the relieving factors.

4) medical history : you have to ask the patient about specific diseases or specific components of the medical history ,not about his general health only Why we ask the patient about his medical history ? 1) the systemic diseases can affect the periodontium 2) it can affect the patient during your work 3) the periodontal conditions have effects on the general health of the patient .

5) smoking : frequency and duration and quantity . 6) family history : especially in aggressive periodontitis cases ( because there is familial aggregation in the aggressive form of periodontitis ).

7) dental history :we mainly ask about previous extractions and if there were any complications due to extractions ,and why did the patient extract his teeth (is it due to periodontal conditions or due to caries ).

8) oral hygiene measures : it give you a baseline of how the patient take care of his teeth and gingiva ,although some patients don't really give you the full truth about that

So we ask the patient : - How often does he brush his teeth What sort of auxiliary oral hygiene methods does he use (mouth rinses, floss) Duration of brushing Type of toothpaste Technique of brushing

2) EXAMINATION :

A) EXTRAORAL EXAMINATION :

By inspection and palpation ,it is important but because our time is restricted we can just inspect the patient ,if everything looks fine ,we can move on to the intraoral examination ,but if u find anything suspicious ,then we carry out the detailed extraoral examination .

- The main components of extraoral examination : 1) face and lips From a periodontal point of view ,We mainly look for competence of the lips (for ex short upper lip or mouth breathing ,sometimes can cause inflammation of the upper gingiva ),also we look for the smile line ,because it affects the esthetic demands of the patient ,if the patient has a high smile line ,the esthetic demands will be more.

2) muscles of mastication

3) lymph nodes

B) INTRAORAL EXAMINATION :

1) Examination of the lining mucosa : - We have to examine the lining mucosa ,tongue , hard palate ,we see if there is any ulceration ,swelling ... 2) Examination of the teeth : It involves examination of : - caries ,restorations . - crowns and bridges . - overhanging restorations - open contacts : it is associated with food impaction, and can associated with isolated pockets (pocketing only in specific site where there is an open contact or overhanging restoration ) - plaque and calculus - staining - assessment of occlusion

We assess the class of occlusion (1 or 2 or 3) But the most important that we assess the occlusion from a parafunctional habits or occlusal trauma point of view ,because the functional relationship between the upper and lower jaws is more important than the static relationship ,for example some of the findings or periodontal conditions that you might face ,might be related to occlusal trauma .

3) Examination of the gingiva : - Inspection : looking for any of the features of inflamed gingiva (redness ,edema ,loss of stippling (but not always reliable ,because only 40% of the population have stippling on the gingiva ). - Gingival Index - Bleeding On Probing

Periodontal Examination :

1) Plaque Index : We have a lot of indices but the most common ones are: A) Loe 1967 plaque index : we use it in our clinics - 0 = NO PLAQUE evident on inspection or passing a probe on the tooth surface . - 1 = no plaque evident on inspection ,BUT CAN BE DETECTED ON PASSING A PROBE OR USING A DISCLOSING AGENT.

- 2 = PLAQUE EVIDENT ON INSPECTION ,but covering no more than the CERVICAL 1\3 OF THE TOOTH . - 3 = ABUNDANT PLAQUE deposit The disadvantage of Loe plaque index is that it needs much time ,so we can't do it for all teeth ,so we select index teeth (representative teeth) ,but those teeth might not be a good representatives for the whole dentition .

B) O'leary Plaque index : please refer to the chart in the slides page 3 - In O'leary plaque index we record 4 surfaces for each tooth - In the chart ,each box refers to a tooth ,and each box is subdivided into 4 parts (surfaces :mesial ,distal,lingual ,and buccal ) - The mesial and distal are examined from the buccal aspect not from the lingual - In O'leary plaque index ,we only record either the presence or absence of plaque ,so it doesn't show the degree of the plaque ,where as in Loe plaque index we have degrees of plaque . C) Gingival index : - 0 = NO SIGNS OF gingival inflammation - 1 = SIGNS OF GINGIVAL INFLAMMATION ARE EVIDENT ,NO BLEEDING ON PROBING . - 2 = SIGNS OF GINGIVAL INFLAMMATION ,WITH BLEEDING ON PROBING

- 3 = SIGNS OF GINGIVAL INFLAMMATION ,WITH SPONTANEOUS BLEEDING ON PROBING.

3) PERIODONTAL CHRTING :

The components of the periodontal charting that need to be recorded : Probing Recession Attachment loss Mobility Furcation involvement .

1) Probing :

- It is measured in millimeters from the gingival margin to the depth of the sulcus or the pocket , using a periodontal probe - The perio probe is graded : 1 , 2 , 3 , 5 ,7 ,8 ,9 ,10 - the force used is 25 grams (the weight of the instrument ,or the force that is enough to cause blanching on your fingernails ). - We don't penetrate the gingival tissues ,so once you feel resistance you stop . - We record six sites per tooth (mesiobuccal , Distobuccal ,midbuccal ,mesiolingual , Distolingual ,midlingual ).

- The probing depth can be different with different operators ,however the difference shouldn't be beyond 1mm - The probing depth recording is dependent on the operator ,the patient ,angulations of the probe ,calculus,the amount of inflammation present . - The angulation of the probe should be parallel with the long access of the tooth . - To record those six sites per tooth ,we We walk around the tooth continuously Without getting the probe out on each site . - For the Patients with orthodontic treatment ,we can't get a 100% correct reading ,but we have to be very close . - In the chart ,we only write down the readings that are 4 mm or deeper at the corresponding site in the PD box - You have to write your measurement mesially or distally or in the middle of the PD box according to corresponding site of the tooth ,so for example if you find that the probing depth on the distal aspect of the lower right first molar is 8 mm, then you have to put 8 in the PD box corresponding to the lower right 6 ,and it should be at distal side of that box . - Bleeding on probing : we don't assess BOP immediately after probing ,so you have to do probing for the whole facial aspect ,then we assess the bleeding on probing .

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For bleeding on probing we place a red dot at the corresponding site in the PD box where the probing depth is recorded .

2) Recession : - Measured from cemento-enamel junction to the gingival margin - Six sites per tooth using perio probe - We draw the recession on the chart on the lines adjacent to each tooth ,each one of these lines represent 1mm gingival recession . 3) CAL : clinical attachment loss - We measure it from the CEJ to the depth of the pocket pr the sulcus . - CAL = recession + probing depth - Whenever we have recession , always write down the probing depth regardless ,even if it was less than 4mm . - So after we finish charting ,then if we find that there is recession in some areas we write it down and then we measure the probing depth and record it .

4) Suppuration : is the production of pus from a pocket ,and if we find it ,we write it down as S letter .

5) Mobility :

- To assess the mobility ,we use the ends of two instruments - Degree 0 = normal movement (less than 0.2mm) - Degree 1 = 0.2-1mm horizontal movement - Degree 2 = 1-2 mm horizontal movement - Degree 3 = more than 2 mm horizontal with rotation .

6) Furcation involvement : it means loss of the bone between the roots of multi rooted teeth ,so we can insert our probe in between . In normal ,what are the furcations in the upper and lower molars ??? In the lower : 2 furcations ; buccal and lingual furcations In the upper : 3 furcations ;buccal ,mesial and distal . how can we assess the furcation involvement ? Using neighbor's probe or the regular probe - At the beginning , We insert the probe vertically ,then horizontally ,if we use our regular probe ,but if we use neighbor's probe ,we insert it horizontally. - Degree 1 : the probe enters the furcation up to 1\3 THE BUCCOLINGUAL DIMENSION OF THE TOOTH . - Degree 2 : the probe enters the furcation MORE THAN 1\3 OF THE WIDTH BUT NOT ALL THE WAY .

- Degree 3 : COMPLETE HORIZONTAL DESTRUCTION (THROUGH AND THROUGH) .

Please refer to the pictures in the slides pages 6 ,7 ,and 8 Page 6 : 1st pic : it shows the different degrees of furcation involvement . 2nd picture : neighbor's probe inserted mesial to the tooth 3rd picture : neighbor's probe inserted buccal to the tooth 4th picture : neighbor's probe inserted distal to the tooth 5th and 6th pics : degree 1 furcation of a lower molar Page 7 : 1st and 2nd pics : same as 5th and 6th pics in the previous page . 3rd and 4th pics :degree 2 furcation involvement 5th and 6th pics : degree 3 furcation involvement . - It is not always possible to know the degree of furcation involvement using radiographs ,so we have to depend on the clinical measurement .

7) Migration : drifting of the teeth out of their original position - For ex ; if a patient presented to having midline diastema , always you have to ask the patient ''is he or she had that space since they were young or it appeared recently ''

Because it can be diastema or migration .

8) Mucogingival relationship :how thick is the attached gingiva , shallow vestibule , high frenal attachment . - Attached gingiva :extends from the free gingival groove to the mucogingival junction ,whereas the keratinized gingiva is the free gingiva and the attached gingiva

Charting : furcation involvement : Grade 1 : V or (triangle without a base) Grade 2 : Grade 3 : (triangle with a base). (shadowed triangle).

keratinized gingiva : If it was less than 3 mm ,we put a star on the facial aspect of the root of the tooth involved . Mobility :it is normally written in roman numbers .

The end

Done by : Omar marzouq

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