Hall's Critical Decisions in Periodontology & Dental Implantology, 5e

Introduction

Each chapter in this book consists of an algorithm or decision tree and explanatory text with illustrations, tables, and photographs. The decision tree is the focus of each chapter and should be studied first in detail. The letters on the decision tree refer the reader to the text, which provides an explanation of the basis for each decision. Boxes with dashed lines have been used in the decision trees to indicate where a decision needs to be made. Boxes with solid lines have been used to indicate an action performed by the practitioner, for example, an invasive procedure. A combination of line drawings and halftones were selected to clarify the text. Cross-references have been inserted to avoid repeating information given in other chapters. Additional readings that are likely to be readily available to the practitioner have been selected and listed at the end of each chapter.

Chapters have been grouped by general concepts in the order that follows the typical sequence of therapy in periodontal practice. An index is included to guide the reader further in locating specific information.

The decisions outlined here relate to typical situations. Unusual cases may require the practitioner to consider alternatives. However, in every case, the practitioner must consider all aspects of an individual patient's data. The algorithms presented here are not meant to represent a rigid guideline for thinking but rather a process to follow and be adapted to the specific needs of a patient.

PART

I

Clinical Examination

I

Medical History

Alan W. Budenz and Walter B. Hall

One of the very first steps after greeting a new patient is to take a complete medical history. At all subsequent visits, a simple question such as Have there been any changes in your health since I last saw you? or How have you been since I saw you last? may elicit an important response. A response such as I found out I am pregnant may seem unimportant to the patient relative to her dental treatment but carries significant considerations for dental practitioners in managing her dental care. Following this simple question, the dentist or hygienist should question the patient more extensively regarding visits to a physician, illnesses, and changes in medication since the patient's last visit. It is essential that this inquiry of medical information should occur before any dental examination or treatment at every appointment. In the treatment record, the practitioner should ensure the medical history was updated by noting, Patient reports no changes in medical history or by recording specific changes that have occurred. The medicolegal importance of such notations cannot be overemphasized.

A A health questionnaire (yes or no format) is useful in making the patient responsible for the accuracy of the medical history. The patient may complete or update such a questionnaire while waiting to see the dentist. The dentist uses this form as a guideline in questioning the patient further about positive answers and writes additional information about the patient's responses and conditions in the patient record.

B The patient's age may be important for developing a treatment plan and as a guide to certain age-related diseases. The date and findings of the patient's last physical examination and the names and addresses of all physicians treating the patient should be noted. It is important to list all the medications that the patient is currently taking and the reasons for their use, including prescription, over-the-counter, alternative/herbal medications, and vitamin supplements. All the important medical conditions should be recorded in a standard and readily reviewable area in the patient's record.

C The clinician should note any previous occurrences of myocardial infarction, coronary artery disease, coronary surgery, and cardiac valve repair/replacement so that precautions such as antibiotic prophylaxis for patients with artificial valves can be taken. Periodontal probing is an invasive procedure that may require prophylactic antibiotics before proceeding. Some patients are aware of blood pressure abnormalities, but many others are not. This is a good time to obtain a baseline blood pressure reading.

D Diabetes is a major problem in successful management of periodontal diseases. For a known diabetic, it should be determined whether (1) the disease is controlled and (2) the patient has visited a physician in the past 3 to 6 months. If the patient is unaware of having diabetes, questions regarding a personal history of periodontal abscesses and blood relatives with diabetes may suggest a problem requiring medical evaluation.

E Infectious diseases, such as hepatitis, acquired immunodeficiency syndrome (HIV/AIDS), and tuberculosis (TB), should be included in the questionnaire. Abnormal bleeding is associated with hepatitis infection. All dentists and dental hygienists are encouraged to receive active immunization against hepatitis B. HIV infection often produces associated periodontal problems (Chapter 57). Questioning with regard to this disease must be managed discreetly. TB is quite prevalent among recent immigrants, and its incidence is resurging among patients, in general. Strict adherence to infection-control practice recommendations from the Centers for Disease Control and Prevention and other agencies is required.

F Hepatitis (see E) and cirrhosis are common problems that affect dental care. Cirrhosis may impair a patient's healing potential. Recurrent kidney infections may require antibiotic prophylaxis before periodontal treatment.

G Patients with seizure disorders may require additional medication before periodontal treatment. Those taking phenytoin (Dilantin®) or other anticonvulsant medications often develop an associated gingival enlargement (Chapter 21).

H Mouth breathing is a compounding factor for periodontal disease. Asthma attacks may be triggered by stress; so, careful

attention must be paid to stress-reducing protocols throughout all appointments. Approximately 15% of inhaler-dependent patients are sensitive to the sulfites present in all local anesthetics containing a vasoconstrictor, contraindicating their use in these patients. Sinusitis may complicate the differential diagnosis of periodontal pain in the maxillary posterior area.

I The importance of maintaining periodontal health both before and during pregnancy cannot be overemphasized. It is significant to note that strong links have been found between periodontal disease in pregnancy and preterm delivery of low-birth-weight infants. Although periodontal treatment may be rendered at any time during pregnancy, caution should be exercised in the first trimester and last half of the third trimester. Pregnancy can modify periodontal disease. Pregnancy gingivitis often does not

respond to treatment until several months after gestation.

J Gastric or duodenal ulcers may complicate periodontal healing because of dietary restrictions. Gingival changes may accompany colitis.

K Various types of cancer present complications in periodontal treatment. Leukemia may be accompanied by gingival enlargement. The prognosis for the more severe or advanced types of cancer can force modification of usual treatment plans. Radiation therapy may make surgical treatment inadvisable. The treating physician should be contacted if chemotherapy is being used or has been used recently.

L Many medicaments and medications used in periodontal treatment are significant allergens that may have to be avoided with sensitized patients.

M Some dermatologic diseases, such as lichen planus, pemphigoid, and pemphigus, have periodontal components.

N Some types of arthritis can restrict dexterity required for plaque removal. Corticosteroid therapy often delays healing after periodontal treatment. Use of aspirin or nonsteroidal anti-

inflammatories (NSAIDs) may increase and/or prolong bleeding during treatment.

O Concerns exist regarding possible infection of total joint replacement prostheses following invasive dental treatment. The American Dental Association has followed the guidelines recommended by the American Academy of Orthopaedic Surgeons (AAOS) in 2003 by recommending antibiotic prophylaxis prior to such treatment for the first 2 years following replacement surgery or for an extended time frame for immunocompromised and other high-risk patients. However, the AAOS has since issued a recommendation to prophylax with antibiotics for an indefinite time following joint replacement surgery. Consultation with the patient's orthopedic surgeon is strongly advised.

P Physical or medical limitations may help explain the etiology of inflammatory periodontal disease if the patient is unable to perform adequate oral hygiene procedures. Such limitations will likely also influence therapy prognosis and treatment planning.

Q Heavy smoking, excessive alcohol consumption, and drug use influence the periodontal diagnosis, prognosis, and treatment planning. Vigorous toothbrushing, especially with a hard brush, may explain root exposure. Self-mutilating (factitious) habits and extra- or intraoral piercings may alter gingival appearance and contribute to periodontal bone loss.

R Medications used for the treatment or management of any medical problem may affect periodontal treatment. Some medications, such as β-blockers, may require changes in anesthetics. Calcium channel blockers and anticonvulsants (see G) may contribute to gingival enlargement. Antibiotics may produce temporary improvements in periodontal disease. Previous and current use of bisphosphonates and other antiresorptive medications (in particular, intravenous use) has been associated with osteonecrosis. Precaution must be taken when treating patients who regularly take aspirin, NSAIDs, clopidogrel (Plavix®), warfarin (Coumadin®), and other blood-thinning medications (Chapter 50). Certain dietary supplements, such as ginseng, ginkgo, garlic, and ginger, can affect blood clotting as can a diet that is heavy in green tea and green leafy vegetables. A dentist must have a recent edition of the Physicians' Desk Reference® or a similar reference to determine possible effects of new medications on the treatment plan. Also useful is a recent edition of Physicians' Desk Reference for Nonprescription Drugs, Dietary Supplements, and Herbs™.

S It is imperative to update the medical history of a recall or continuing patient at every visit. New medical problems, altered status of previously diagnosed medical problems, and changes in medications can affect periodontal treatment.

Additional Readings

American Academy of Orthopaedic Surgeons & American Dental Association. Prevention of orthopaedic implant infection in patients undergoing dental procedures. Evidence-based guideline and evidence report. http://

www.aaos.org/research/guidelines/PUDP/PUDP_guideline.pdf. Accessed January 30, 2013.

Klokkevold PR, Mealey BL, Otomo-Corgel J. Periodontal treatment of medically compromised patients. In: Newman MG, Takei HH, Klokkevold PR, Carranza FA Jr, eds. Carranza's Clinical Periodontology. 11th ed. St. Louis, MO: Elsevier Saunders; 2012:396-411.

Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the Medically Compromised Patient. 8th ed. St. Louis, MO: Elsevier Mosby; 2013.

Newman MG, Takei HH, Klokkevold PR, Carranza FA Jr, eds. Carranza's Clinical Periodontology. 11th ed. St. Louis, MO: Elsevier Saunders; 2012:340-343.

Schifferle RE, Mealey BL, Rose LF. Medical and dental history. In: Rose LF, Mealey BL, Genco RJ, Cohen DW, eds. Periodontics: Medicine, Surgery and Implants. St. Louis, MO: Elsevier Mosby; 2004:912-920.

Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis. Guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Journal of the American Dental Association. 2008;139(suppl):3S-24S.

2

DENTAL HISTORY

Walter B. Hall

Taking and recording a dental history often is a neglected but extremely important aspect of examination, risk assessment, diagnosis, prognosis, and treatment planning. Because many patients are treated by more than one dentist, this history should be updated regularly. The accuracy and reliability of facts from the dental history are always open to question. The patient's own answers, however, are important to record because any inaccuracies may influence treatment. If the facts are not consistent with what is seen in the mouth or on radiographs or with the dentist's knowledge of periodontal problems and their treatment, more extensive questioning may be necessary.

A A questionnaire (yes or no format) is useful for gathering data. The patient can complete such a questionnaire while waiting to see the dentist. Space should be provided on the questionnaire for a new patient to indicate the date of the last dental visit and its purpose, the former dentist and reason for changing, and whether the radiographs or other materials are available.

B Further questioning by the dentist is necessary to determine details such as the reason a certain procedure was done, the location in the mouth, and the time.

C The patient should note which teeth are missing, and the dentist should ask when they were removed (or if they never appeared) and why.

D The patient may know that the third molars were extracted or are impacted. The dentist should ask about postsurgical problems if the molars were extracted, including when the surgery was done. If the third molars are present, the dentist should ask whether the patient has ever been told they should be removed, and, if so, the reason surgery was not performed. The dentist should ask about any symptoms (such as pain or swelling) that the patient has had in those areas.

E By asking a general question about other surgeries, the dentist may learn about previous fractures of the jaw or oral tumors that have been removed. The dentist must use follow-up questions for details.

F The dentist should ask about restorations such as crowns, bridges, removable prostheses, and implants. If any are present, the dentist should ask the reason they were placed, when they were placed and by whom, and whether earlier restorations preceded them. A patient's knowledge of these events is likely to be unimpressive.

G The dentist should ask whether the patient has any endodontically treated teeth, and, if present, when they were treated, and, in cases of atypical or inadequate root canal therapy, where they were done. If endodontically treated teeth are indicated, the dentist should ask about other treatments (e.g., apicoectomies and root resections).

H The dentist should ask whether the patient has had regular dental cleanings (periodontal maintenance) or deep cleanings (scaling/root planing). If so, the dentist should ask when the last one was done and by whom, and the frequency.

I The dentist should ask whether the patient has had bite problems or jaw pain. If so, a detailed history of the problems, their diagnoses, treatments, and the dates of these events should be annotated.

J The dentist should ask whether the patient has had any orthodontic treatment. If so, the dentist should record its nature, time of treatment, extractions, the patient's satisfaction with the outcome, and any relapse.

K The dentist should ask about clenching and grinding (i.e., bruxism, night grinding) and record the patient's concept of the problem, noting whether the problem can be related to particular life or dental events. Prior use of a night guard should be noted as well.

L For a periodontal patient, the periodontal history is most important. An essential question is whether the patient has had a previous periodontal problem diagnosed. If not, questions regarding bleeding, swollen gingiva, pain, or gingival ulcerations may reveal that periodontal problems have existed. If a previous diagnosis was made, the types of treatment and the time of treatment should be recorded. If no previous treatment occurred but was suggested, the dentist should ascertain the reason why no treatment was performed. If previous treatment was performed, it should be determined whether there were acute problems such as necrotizing ulcerative gingivitis, necrotizing ulcerative periodontitis, or a periodontal abscess. Also, when and how they were treated should be noted.

M A recall periodontal patient may have had dental problems or treatment by other dentists since the last visit. The dentist should update the dental history and specifically ask whether any problems have occurred and also about the response to earlier treatment, oral hygiene measures used, and the dental treatment performed elsewhere.

Additional Readings

Newman MG, Takei HH, Klokkevold PR, Carranza FA Jr, eds. Carranza's Clinical Periodontology. 11th ed. St. Louis, MO: Elsevier Saunders; 2012:341-345.

Rose LF, Mealey BL, Genco RJ, Cohen DW, eds. Periodontics: Medicine, Surgery and Implants. St. Louis, MO: Elsevier Mosby; 2004:919-920.

Wilson TG, Kornman KS, eds. Fundamentals of Periodontics. 2nd ed. Carol Stream, IL: Quintessence; 2003:642.

3

PLAQUE CONTROL HISTORY

Walter B. Hall

A history of plaque control is important to establish during the examination of a new or recall patient. What the patient is doing, has done, or has been advised to do to control plaque accumulation can explain the status of plaque control at the time of the examination. The dentist can also collect data of a subjective

nature. The way a patient responds to questions regarding plaque

control efforts may be as important to helping the dentist as the answers themselves. If the tone of the answers is negative, the dentist must expend a greater effort or find a new approach to sensitize the patient to the need for personal effort. If the patient cannot be motivated or is unable to perform adequate plaque control, the dentist's responsibilities become greater, and more frequent visits will be necessary. The patient should be made aware that the cost in money, time, and discomfort will be greater; this may help motivate the patient.

A For a new patient, a history of plaque control regarding past and current practices is required. Past practices, such as using a hard or medium brush with a scrub stroke, may be the reason why recession is present. Relating past brushing to current techniques may indicate when recession occurred and whether it is stable or ongoing. These are important factors in deciding whether gingival grafting is needed. It is important to ascertain how long the patient has been flossing, the way the floss is used, and what the patient is trying to accomplish. Improper use of floss with a shoe-shining motion may explain the origin of floss cuts. If adjuncts such as water spray or irrigation devices, interproximal brushes, wooden interdental cleaners, toothpicks, or a toothpick-in-holder have been used, the manner of their use and the patient's understanding of their rationale should be noted. Damage relating to the misuse of such devices and the reasons for discontinuing the use of a device should also be noted.

Documenting the patient's current practices in regard to brushing, flossing, type of dentifrice and mouth rinse, and the use of adjunctive devices is critical. The adequacy of the approaches should be noted as satisfactory or needing change concerning what is being used and how. If the patient is doing something different than instructed, it should be noted and the action explained. A plaque index is recorded at this initial examination.

B The recall patient should demonstrate, at least by motions, the current practices. If the patient has stopped using all recommended devices or has changed the methods of the use, the reason for doing so should be explained and the degree of success with the revised approach should be evaluated. Occasionally, a patient may devise a better means of using a device than the method taught. If not harmful, it may be advisable to allow the patient to continue using the new approach. When the examination is performed, the stated practices can be compared with results and the discrepancies explored. A plaque index is recorded this time as well.

C If a patient's plaque control program needs to be changed, a powered toothbrush may be helpful for physically impaired individuals. For patients whose flossing is inadequate, a change to an adjunctive device often works wonders. An interproximal brush is best if space between the teeth and roots is large enough to accommodate. If spaces are too narrow, various interproximal sticks can be an excellent alternative.

Additional Readings

Lang NP, Lindhe J. Clinical Periodontology and Implant Dentistry. 5th ed. Oxford, UK: Blackwell Munksgaard; 2008:705-733.

Perry DA. Plaque control for the periodontal patient. In: Newman MG, Takei HH, Klokkevold PR, Carranza FA Jr, eds. Carranza's Clinical Periodontology. 11th ed. St. Louis, MO: Elsevier Saunders; 2012:452-460.

Wilson TG, Kornman KS, eds. Fundamentals of Periodontics. 2nd ed. Carol Stream, IL: Quintessence; 2003:349, 358-362.

4

RADIOGRAPHIC EVALUATION

Gail F. Williamson and Edwin T. Parks

Radiographs are indispensable to the assessment of conditions that affect the prognosis and treatment of periodontal disease. Radiographic assessment of the patient begins with the history and intraoral examination. The clinician should determine the areas to be evaluated, scope of dental disease, patient morphology, anatomic challenges, and type of radiographs before any images are exposed. Exposure parameters (kVp, mA exposure time) must be adjusted for both patient size and tooth type to produce images with adequate density and contrast. Digital receptors provide instantaneous images, while film-based imaging requires chemical processing to generate a visible image. Image quality can be significantly undermined if images are processed in exhausted chemistry.

A Before any radiograph is interpreted, it must be evaluated for technical quality. Radiographs that are distorted provide little diagnostic information and can produce artifacts that can be misinterpreted. The paralleling technique produces the most anatomically accurate intraoral images. The receptor is placed parallel to the long axis of the tooth, and the center of the x-ray beam is directed perpendicular to the image receptor. Improper positioning of the receptor or central ray will produce errors in vertical angulation (elongation, foreshortening) and horizontal angulation (overlapped interproximal contacts). Radiographic images should be of adequate density and contrast. Digital imaging allows the clinician to enhance the image, but it should be used to improve an acceptable image rather than salvage an inadequate image. Panoramic images can provide an overview of the maxillofacial structures but do not produce the spatial resolution seen with intraoral images (periapical, bitewing). Positioning errors will also distort the panoramic image. Care must be taken to align the patient in the focal trough of the panoramic machine to minimize distortion.

B Once the radiographic images are assessed for technical quality, normal anatomic structures must be identified. Normal anatomic structures can sometimes mimic pathology (e.g., superimposition of mental foramen over apices of premolars). Critical anatomic structures include the incisive foramen and maxillary sinuses in the maxilla and mental foramina and inferior alveolar canal space in the mandible. Panoramic images provide a more complete view of the maxillary sinuses and the bony components of the temporomandibular joints. Cone beam computed tomography is indicated when three-dimensional imaging is necessary to evaluate and plan implant placement and/or failed endodontic treatment.

C In health, the bony alveolar crest is approximately 1 to 2 mm apical to the cementoenamel junction (CEJ). The bone margin follows the plane of adjacent CEJs with the anterior crest narrow and pointed in shape and the posterior crest flat and angular in appearance. The alveolar crest is contiguous with the lamina dura of adjacent teeth (Figure 4-1). A distinct radiopaque cortical outline of the alveolar crest indicates periodontal stability, whereas active disease results in a crest that appears irregular with a loss of radiopacity. This observation is not pathognomonic of periodontal disease as it can be seen in healthy individuals as well.

Figure 4-1 Bitewing radiograph depicting normal presentation of the posterior alveolar bone crest.

Note: normal distance from CEJ, dense cortical outline, and sharp angle formed with the lamina dura of adjacent teeth.

In health, the periodontal ligament (PDL) space often appears slightly wider near the cervical of the tooth and at the apex and appears thinner midroot. The radiographic pattern of trabecular bone is quite variable from person to person, as well as area to area of the jaws. Careful observation and comparison is necessary to determine whether variations are normal or represent disease.

Radiographs cannot demonstrate the activity of the disease, but only its history. Horizontal bone loss appears as equal loss across an interdental or interradicular area that occurs parallel to adjacent CEJs with measurements greater than 2 mm from the CEJ (Figure 4-2). Vertical bone loss appears angular to adjacent CEJs with one tooth having more bone loss than its neighbor with measurements greater than 2 mm from the CEJ (Figure 4-3). Horizontal bone loss typically is more generally distributed as it involves multiple teeth, while vertical bone loss tends to be more localized.

Bone loss can be mild, moderate, or severe. Early radiographic evidence of mild periodontitis can manifest as blunting of the crests, loss of cortical density, mild loss in height, and loss of the sharp angular appearance of the posterior crest. With moderate disease, more loss in height is evident with more generalized distribution of horizontal bone loss, localized vertical bony defects, and furcation involvement. Severe periodontitis demonstrates extensive horizontal and/or vertical bone loss and furcation involvement such that the teeth have inadequate support to maintain normal position and function. Alterations in the trabecular pattern of bone, PDL, and lamina dura can be observed as well. Typically, the clinical examination demonstrates more severe destruction than what can be observed radiographically.

Figure 4-2 Vertical bitewing demonstrating horizontal bone loss in the right mandibular molar area.

Note: furcation involvement with widened PDL.

Figure 4-3 Vertical bitewing depicting vertical bone loss on the distal aspect of left mandibular second premolar tooth.

Figure 4-4 Vertical bitewing demonstrating horizontal and vertical bone loss, as well as caries and periapical pathosis.

The crown-to-root (C:R) ratio is another important consideration in the radiographic assessment of periodontal disease. The C:R ratio is determined according to the amount of root remaining in bone compared with the amount of tooth above the bone level. In addition, changes in the continuity of the lamina dura and widening of the apical PDL indicate possible pulpal involvement. Occlusal trauma can also result in a widened PDL and thickened lamina dura, although the widening is also seen in the PDL along the lateral surfaces of the tooth. Trabeculation can also increase with hyperfunction. In hypofunction, the PDL becomes atrophic and is narrower, along with a diminished lamina dura. Some conditions, such as hyperparathyroidism, can result in the loss of a distinct lamina dura. A variety of non-periodontal conditions visible on radiographs can affect prognosis and treatment.

D Evaluation of the teeth includes the assessment of the coronal and root components. The coronal portion should be assessed for morphology, the presence of caries, adequacy of restorations, and relationship with other teeth (Figure 4-4). Abnormal crown morphology and dental caries can create areas of plaque accumulation that are difficult for the patient to clean. Plaque accumulation and food impaction can result from poorly contoured restorations, lack of marginal integrity, marginal ridge discrepancies, and open contacts. Rotation and inclination of the crowns can also create areas that interfere with plaque control.

The pulp chamber and canals should also be evaluated. The presence of pulpal calcifications or decreased size of the pulp chamber could affect the ability to perform endodontic treatment. An increase in the size of a pulp chamber can indicate internal resorption. Diminished dimensions of root canals can influence the success of endodontic therapy as well. The sudden loss of pulp canal dimensions at the midroot level can indicate the presence of two canals (and potentially two roots).

The number, shape, and distribution of the roots of a tooth can influence both treatment planning and prognosis. Roots that are short will have an effect on the determination of C:R ratio. A bulbous root has a better prognosis than a thin root. The distribution of the roots of a multirooted tooth will affect the prognosis and plan of treatment as well (e.g., teeth with widely distributed roots such as a mandibular first molar can tolerate a greater functional load than a tooth with fused roots). The morphology of the root trunk and location of furcations can influence the treatment and prognosis of the tooth.

Additional Reading

Perschbacher S. Periodontal diseases. In: White SC, Pharoah MJ, eds. Oral Radiology Principles and Interpretation. 6th ed. St. Louis, MO: Mosby Elsevier; 2009:282-294.

Interpreting Bone Loss

on Radiographs and

Bone Sounding

5

Min Liang

An accurate interpretation of the bony architecture in relation to the soft tissue of the periodontium is one of the single most important determinants for therapy selection. Though the probing depth and soft tissue measurements can provide a clear picture of the soft tissue architecture, interpretation of the bony architecture is based on an acquired skill set. This skill set entails a combination of clinical experience, a study of the literature, and practical technique involving bone sounding.

A Radiographs provide useful information about bone levels and patterns of bone loss that cannot otherwise be obtained through routine clinical examination. Many factors affect the diagnostic quality of radiographs such as angulation of the x-ray beam, exposure time, film processing, and the type of film. A proper radiograph should show: (1) overlapping of the buccal and lingual cusps of molars–premolars with little or no occlusal surface, (2) open contacts without any overlapping of the proximal surfaces, and (3) enamel caps and pulp chambers. The radiograph should also have appropriate density and contrast to facilitate an accurate interpretation.

B Radiographs indirectly estimate bone loss by showing the remaining bone level, which is assessed by measuring the distance between the cementoenamel junction (CEJ) and the alveolar crest, or as a ratio of root length. In a healthy periodontium, the distance between the alveolar crest and the CEJ is 2 mm or less (Figure 5-1). With periodontitis, this distance is > 2 mm from the CEJ, and the distance to the gingival crest is variable. Although crestal lamina dura is an indicator of a healthy periodontium, the absence of a lamina dura does not necessarily correlate with clinical inflammation, periodontal pockets, attachment loss, or pulpal pathosis.

Traditional intraoral radiographs provide a two-dimensional image of osseous structures and give valuable information to evaluate interproximal bone level. However, this technique does not accurately reveal bony defects on the facial or lingual surfaces because of root superimposition. In addition, traditional radiographs routinely underestimate the amount of bone destruction. A clinical examination may show significant attachment loss; however, radiographic images may not indicate bony destruction until 6 to 8 months later. Typically, radiographs do not show bone loss until mineral loss has reached at least 30%.

C Patterns of bone loss are classified as horizontal and vertical. Horizontal bone loss is the most common pattern and occurs equally on both mesial and distal aspects of proximal teeth such that the alveolar crest is parallel to an imaginary line connecting the CEJs of adjacent teeth (Figure 5-2). Vertical (angular) bone loss occurs at an acute angle to the tooth surface such that the crestal border of the alveolar bone shows an unparallel or oblique angulation to an imaginary line connecting the CEJs in adjacent teeth (Figure 5-3). Further discussion of the various types of vertical defects is in Chapter 14.

Figure 5-1 Normal alveolar crest and lamina dura.

D Bone sounding or transgingival probing (Figure 5-4) is a safe method for determining underlying osseous architecture that is done under local anesthesia. No long-term harm is associated with this diagnostic technique. Bone sounding involves the insertion of a periodontal probe through the soft tissue until bone is felt. The bone sounding measurements correlate closely to the actual bone level. This is usually performed presurgically to ascertain the architecture of certain osseous defects or during the time of surgery for final confirmation of the osseous architecture prior to incision design.

Figure 5-2 Horizontal bone loss.

Figure 5-3 Vertical (angular) bone loss on distal aspect of mandibular first molar with radiolucent furcation.

Figure 5-4 Bone sounding technique is performed under local anesthesia with a periodontal probe.

E Bone sounding may provide a more accurate assessment of the presence and extent of facial and lingual (palatal) bony defects. Radiographs do not accurately depict these lesions, which may be obscured due to root/bone density and two-dimensional overlap. With regard to vertical (angular) defects, bone sounding may provide insight into the configuration, extent, and number of remaining bony walls (Chapter 14).

F Bone sounding can be used to improve the accuracy of furcation diagnosis. In patients with moderate to severe periodontal disease, furcations may occur with multirooted teeth. Radiographic images, such as widening of the periodontal ligament space, furcation arrows, or radiolucent images at the apices of the interradicular bony crest, are suggestive of a possible furcation. It is more difficult to detect a bony defect on the buccal aspect of a maxillary molar than that of a mandibular molar because of the overlapping of the palatal root with the defect. A small triangular radiolucent shadow across the mesial or distal root of maxillary molars may be associated with grade II and III furcations (Glickman, 1953). The lack of radiographic evidence of bone loss at a furcation does not necessarily indicate the absence of a bony furcation.

Additional Readings

Armitage GC. Periodontal diseases: diagnosis. Ann Periodontol. 1996;1(1):

37-215.

Deas D, Moritz AJ, Mealey BL, McDonnell HT, Powell CA. Clinical reliability of the furcation arrow as a diagnostic marker. J Periodontol. 2006;77(8):1436-1441.

Goodson JM, Haffajee AD, Socransky SS. The relationship between attachment level loss and alveolar bone loss. J Clin Periodontol. 1984;11(5):348-359.

Hansen BF, Gjermo P, Bergwitz-Larsen KR. Periodontal bone loss in 15-year-old Norwegians. J Clin Periodontol. 1984;11(2):125-131.

Hausmann E, Allen K, Clerehugh V. What alveolar crest level on a bite-wing radiograph represents bone loss? J Periodontol. 1991;62(9):570-572.

Källestål C, Matsson L. Criteria for assessment of interproximal bone loss on bitewing radiographs in adolescents. J Clin Periodontol. 1989;16(5):300-304.

Kim HY, Yi SW, Choi SH, Kim CK. Bone probing measurement as a reliable evaluation of the bone level in periodontal defects. J Periodontol. 2000;71(5):729-735.

Ursell MJ. Relationships between alveolar bone levels measured at surgery, estimated by transgingival probing and clinical attachment level measurements. J Clin Periodontol. 1989;16(2):81-86.

Yun JH, Hwang SJ, Kim CS, et al. The correlation between the bone probing, radiographic and histometric measurements of bone level after regenerative surgery. J Periodont Res. 2005;40(6):453-460.

6

PERIODONTAL EXAMINATION

Gary C. Armitage

A periodontal examination is a mandatory part of the overall evaluation of the oral health status of all dentulous individuals seeking dental care. The overall evaluation starts with the collection of information on the patient's chief complaint and medical/dental histories followed by an extraoral inspection of the head and neck. Components of a complete oral examination include, but are not limited to, a detailed assessment and recording of decayed and missing teeth, nature and adequacy of existing dental restorations, occlusal/functional properties of the dentition, and a thorough inspection of the soft tissues of the oral cavity and oropharynx. Preliminary findings from an oral examination are often used to determine what type of radiographic survey (e.g., full mouth periapical radiographs) is required to fit the needs of an individual patient.

A periodontal examination is designed to assemble specific information about the clinical status of the supporting tissues of the teeth. The collected information is used to arrive at a list of probable conditions or diseases that best describes or fits the patient's periodontal status. This list is sometimes referred to as a differential diagnosis. On such lists, the probable diseases or conditions that best fit the patient's signs and symptoms are usually ordered from most likely to least likely. A diagnosis is important since it sets the stage for thinking about a possible treatment plan. No oral examination is complete unless a thorough inspection of the periodontal tissues has been performed.

A Etiological Agents and Clinical Signs of Inflammation. Information collected during a complete periodontal examination includes assessments of probable etiological agents such as the presence of plaque and calculus and clinical signs of periodontal inflammation (e.g., redness, swelling, bleeding on probing, purulent exudate). Any local factors that make it difficult to perform adequate oral hygiene are also recorded since control of periodontal infections requires correction or removal of these factors. Commonly found local factors that can contribute to the pathogenesis of periodontal infections include poor dental restorations (e.g., subgingival overhangs, poor contours, open interproximal contacts), crowded/malpositioned teeth, and anatomical dental defects (e.g., coronal–radicular grooves).

B Assessment of Periodontal Damage. A periodontal examination also includes a careful assessment of past damage to periodontal tissues. A mandatory initial assessment of damage is measurement of the probing depths (PD) at six locations around all teeth. These locations are the mesiofacial, midfacial, distofacial, mesiolingual, midlingual, and distolingual. PD is the distance in millimeters from the crest of the gingival margin to the base of the probeable crevice between the tooth and gingiva. At healthy sites, these crevices are usually only a few millimeters deep and are the habitat for a diverse community of microorganisms that make up the normal periodontal microbiota. Bacteria at these sites live in a homeostatic host–microbial relationship. Anything that disrupts this health-associated homeostasis, such as the complete cessation of all oral hygiene procedures, will upregulate host innate and adaptive immune responses to the increased microbial challenge. The overall result is clinically observable inflammation. If the host–microbial homeostasis is not restored (e.g., by resumption of oral hygiene), the gingiva will remain inflamed for prolonged periods. The persistence of chronic inflammation often leads to tissue destruction that is clinically manifested by detachment of tissue from the tooth and formation of a periodontal pocket. PD measurements provide objective assessments of this detachment and the magnitude of the habitat for the subgingival microbiota. Reduction in PD is considered a desirable outcome of periodontal therapy because it is easier to restore and maintain the host–

microbial homeostasis at shallow sites than at deep sites. Therefore, full mouth PD measurements provide a preliminary assessment of a potential target of periodontal therapy.

In addition to PD, assessments of periodontal damage are made that include gingival recession, clinical attachment level (CAL), and loss of alveolar bone. Gingival recession refers to the distance from the gingival margin (GM) to the cementoenamel junction (CEJ). If the GM is coronal to the CEJ, the GM-CEJ measurement is recorded as a negative value. If the GM is apical to the CEJ, the GM-CEJ measurement is recorded as a positive value. The CAL is derived by adding or combining the PD and GM-CEJ measurements. Loss of alveolar bone is evaluated by inspection of radiographic images of the teeth and supporting structures. Radiographs should be used as an adjunct to, not a replacement for, the periodontal examination.

C Other items that should be collected as part of a periodontal examination are deviations from normal periodontal anatomy (e.g., altered gingival contours, lack of keratinized gingiva), position of the mucogingival junction, tooth hypermobility, furcation involvement, occlusal relationships, and root morphology/length. Any factor that might affect the development of periodontal disease or interfere with its successful treatment should be noted. Findings from the detailed periodontal examination are combined with information obtained from the medical/dental histories and results of the extraoral and oral exams to arrive at an overall periodontal diagnosis. The diagnosis is the starting point for thinking about the type of treatment that is best suited to fit the patient's specific needs.

Additional Readings

Armitage GC. The complete periodontal examination. Periodontol 200.2004;34:22-33.

Armitage GC. Periodontal diagnoses and classification of periodontal diseases. Periodontol 2000.2004;34:9-21.

7

Clinical Signs of Gingival Health and Inflammatory

Periodontal Diseases

M. Robert Wirthlin

The objectives of this chapter are to describe the clinical and histological features of the gingiva in health and of gingival inflammation as it progresses from the initial lesion to the advanced state. In periodontal health, there are certain subjective measures of color, texture, form, and consistency that are expected. Clinical signs along with symptoms and case patterns are essential aids in periodontal disease classification.

A The color is based on gingival tissue that has a thin, stratified squamous surface epithelium, which is slightly keratinized or parakeratinized and translucent. Beneath the epithelium at the junction with the connective tissue, there may be a sprinkling of melanin pigment and melanocytes, with the amount varying from patient to patient. In the superficial connective tissue under the epithelium, there are capillary loops that project up into the dermal papillae found between the rete ridges of the epithelium. All capillary loops are not open at once but respond to homeostatic activity of their precapillary sphincters. Within the capillaries are the red blood cells, and it is the reddish heme pigment in the red blood cells that is the basis for most gingival color.

Healthy gingiva is often described as coral or salmon pink, but that is too specific. Just as each individual has a unique facial complexion, each individual has a unique gingival complexion. Blonde, blue-eyed individuals are expected to have lighter pink gingiva than those with brown eyes and dark hair (Figure 7-1). To determine what is normal for a patient, the clinician must look at an area of attached gingiva not affected by disease. Usually, the area of the lateral incisors will have the broadest zone of attached gingiva where that individual's normal color can be determined. From this attached gingiva standard, the clinician should compare the color observed with that of the nearby gingival margins and interdental papillae (Figure 7-2). If all areas have an even distribution of a basic pink, that is a sign of good health or successful therapy. It is the difference in color from the accepted norm that is important and not any specific color of red. In individuals with an unusually dense melanin layer in the anterior labial surfaces of the gingiva, the lingual and posterior surfaces may be an alternative gingival standard. It should be noted that the gingival standard should be from areas of attached gingiva because mucosa is most often nonkeratinized, without melanin, and has connective tissue that is more loose and less collagenous—all resulting in the oral mucosa appearing redder than healthy gingiva.

Inflammation involves a very complex interaction of neurovascular, cellular, and immunological reactions to trauma or irritants. The first release of cytokines from injured cells results in a temporary vasoconstriction followed by a vasodilation of the precapillary sphincters, which relax as more and more capillary loops are opened. This is seen as increased redness because there is more of the pigment heme to view. The color will reflect the degree of oxygenation of the hemoglobin. Rubor or redness is the first cardinal sign of inflammation (Figure 7-3).

The red color may seem faint if the stratified squamous epithelial covering is thickened by excess keratin, as in a leukoplakia, and becomes opaque. As the inflammation progresses, fluids of greater and greater specific gravity are released through the venule and capillary walls and eventually the blood itself may enter the tissues and become deoxygenated. Such an ecchymosis will color the marginal tissues blue, as in thrombocytopenia, or extend into the attached gingiva, as in leukemia. If the serum contains heavy metal salts as in lead poisoning, the lead may react with sulfides produced by gingival pathogens and create blackness in the gingival margins. An immunocompromised patient may have marginal tissues that have been invaded by microorganisms (perhaps, Candida), and despite good plaque control, present a linear gingival erythema sign of inflammation.

Figure 7-1 This is an example of healthy gingiva: stippling of the attached gingiva and reddish appearance of the mandibular mucosa.

Figure 7-2 Another perspective of healthy gingiva which is more reddish in appearance. Gingival health is determined by comparing one area with a representative healthy zone.

It is useful to develop a vocabulary to describe the observed changes, and the red hues may be called flushed, ruddy, rosy, ruby, florid, bloodshot, glowing, burning, cardinal, or crimson. The host oxygenation will affect the heme's red value and chroma; so in a chronic inflammation, grays and blues will affect the color perceived and might be called dusky, dull red, livid, magenta, or cyanotic. Calculus deposits are often blackened by repeated gingival bleeding and degenerated heme pigments, and the black might be visible through thin and edematous gingival margins. In a similar way, restoration margins may show through and add a grayness to the red. In an acute situation, the reds may be called bright red, fiery, flaming, or lurid.

In a long-term clinical case with years of fluctuation between chronic inflammatory periodontal disease and repair following treatment sessions, tissue redness may be affected by a proliferation of capillaries, and, even with thorough plaque control, a dull marginal redness may persist for some time (Figure 7-4). The hormone progesterone has a role in capillary proliferation and will influence the capillaries and redness of the gingiva in pregnancy and the menstrual cycle. Some authors claim that cigarette smoking affects the vascular response, and smokers, therefore, display less redness.

Redness that extends from the papillae and margins into the attached gingiva is an ominous sign and might be associated with accumulation of root surface deposits and loss of clinical probing attachment. Any redness of the gingiva that does not respond within a week to clinical debridement and improved patient hygiene might require a biopsy as it may be a manifestation of Kaposi's sarcoma or a squamous cell carcinoma.

Figure 7-3 Acute gingival inflammation associated with poorly controlled diabetes. The gingival margin is erythematous and enlarged.

Figure 7-4Chronic inflammation of the papilla between teeth #2 and #3. Recurrent abscess formation and calculus on tooth #3 have resulted in a change in color, form, texture, and contour of the gingiva on the lingual aspect.

B The texture of the surface of healthy attached gingiva is stippled, similar to the surface of an orange. It is best observed in a dry state following a gentle stream of air or blotting with a gauze sponge. On close inspection, stippling is seen as irregular round, oval, or short linear depressions, usually less than 1 mm size. The stipples are oriented with convergence of underlying connective tissue and epithelial ridges. Stippling is most prevalent in the attached gingiva in interdental areas and often extends onto the surface of interdental papillae and the free gingival margin. At the mucogingival junction, the surface abruptly changes from a matte to a shiny, smooth surface on the alveolar mucosa. Gingival stippling is lost with onset of inflammation, and such areas are termed smooth, shiny, or !glossy.

C The form of the gingiva is based on the clinician's concept of the ideal from observation of many cases of gingival health. The ideal interdental papilla between contacting teeth should have steep, flat labial and lingual walls and fill the interdental embrasure. The papilla should be examined from the front for blunting or recession of the tip of the papilla. It should be examined from an occlusal view for convex, rounded, or bulbous walls. A healthy papilla is pyramidal, not conical. Between contacting teeth, in a sagittal plane cross-section from labial to lingual, two peaks will be visible at the tip: one on the labial and another on the lingual. There will be a depression between the peaks called a col. The two peaks and the col are adaptations around the contact area between the teeth. The broader contact areas of molars make the interdental pyramid longer in a buccolingual direction. If the teeth are not in contact, the tip of the papilla may be flattened or even saddle-

shaped depending on the width of the tooth separation.

The clinician's concept of healthy margins includes those that are thin, knife-edged, and tightly adapted to the crown beneath its height of contour. From a labial view, the margins have a scalloped form as they progress from tooth to tooth. The degree of scalloping will vary with tooth form. Individuals with a tapering tooth form will have a more accentuated scalloping compared with those with a square tooth form. When the teeth are crowded, the margins will be thicker on the labial of teeth in linguoversion and thinner on the labial over teeth in labioversion. If the tooth in labial version is off the ridge, there may be a dehiscence in the alveolar bone and a margin that is susceptible to recession.

The vocabulary for changes in gingival margin form might include the terms thickened, blunted, rolled, receded, cleft, eroded, and irregular. With necrotizing ulcerative gingivitis (also known as trench mouth), the interdental papillae may have the tip missing as if it was punched out and replaced by a