Clinical Diagnosis

PART II

Chetan Basnet
BDS IV year
Roll No. 2
CONTENTS

-EXAMINATION OF PERIODONTIUM

 THE PERIODONTAL SCREENING AND RECORDING

SYSTEM
 LABORATORY AID TO CLINICAL DIAGNOSIS
NUTRITIONAL STATUS
-

-PATIENT ON SPECIAL DIET FOR MEDICAL REASONS

-BLOOD TESTS
 Examination of the Periodontium

• The periodontal examination should be systematic, starting in the

molar region in either maxilla or mandible and proceeding around the
arch. It is important to detect the earliest signs of gingival and
periodontal disease.

• Charts to record periodontal and associated findings provide a guide

for a thorough examination and record of the patient'scondition. They
are used for evaluating response to treatment and for comparison at
recall visits.
• A method for periodontal screening and recording (PSR) has been
developed jointly by the American Academy of Periodontology and the
American Dental Association, with the support of the Procter &
Gamble Company.
• This method is designed for the general dental practitioner, and its
purpose is to identify patients requiring periodontal care and to
determine, in general terms, the type of care required.
Plaque and Calculus.

• There are many methods for

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

• Radiograph may sometimes reveal heavy calculus deposits

interproximally and even on the facial and lingual surfaces.
• The gingiva must be dried before accurate observations. Light
reflection from moist gingiva obscures detail. In addition to visual
examination and exploration with instruments
• Firm but gentle palpation should be
used for detecting pathologic
alterations in normal resilience, as
well as for locating areas of pus
formation.

• Each of the following features of the

gingiva should be considered:
color,
 size,
contour,
consistency,
 surface texture,
position,
 ease of bleeding, and
pain.
• Gingival inflammation can produce two basic types of tissue response:
1. edematous and
2. fibrotic.
• Edematous tissue response is characterized by a smooth, glossy,
soft, red gingiva.

• In the fibrotic tissue response, some of the characteristics of

normalcy persist; the gingiva is more firm, stippled, and opaque,
although it is usually thicker, and its margin appears rounded.
•Use ofClinical Indices in Dental Practice:
The Gingival Index and the Sulcus Bleeding Index appearare most useful
and most easily transferred to clinical practice.
• The Gingival Index (Loe and Silness) provides an assessment of
gingival inflammatory status that can be used in practice to compare
gingival health before and after Phase I therapy or before and after
surgical therapy.
• It can also be used to compare gingival status at recall visits.
 The Sulcus Bleeding Index (Miihlemann and Son).

• It is useful for detecting early

inflammatory changes and
presence of inflammatory
lesions located at base of the
periodontal pocket, an area
inaccessible to visual
examination.
• Examination for periodontal pockets must include
consideration of the following:
• presence and distribution on each tooth surface,
• pocket depth,
• level of attachment on the root and
• type of pocket (suprabony or intrabony).
Periodontal pockets around lower anterior teeth, showing rolled margins, edematous
inflammatory changes and abundant calculus
Signs And Symptoms

• Probing is the only reliable

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

• There can also be foul taste in

localized areas, sensitivity to
hot and cold, and toothache in
the absence of caries
 Detection of Pockets

• The only accurate method of detecting and measuring periodontal

pockets is careful exploration with a periodontal probe
• Pockets are not detected by radiographic examination.
• The periodontal pocket is a soft tissue change
• Radiographs indicate areas of bone loss where pockets may be
suspected but :
1) they do not show pocket presence or depth
2)They show no difference before or after pocket elimination unless
bone has been modified
•Guttapercha points or calibrated silver points 19 can
be used with the radiograph to assist in determining the
level of attachment of periodontal pockets

Blunted silver points assist in locating the base of pockets

 Pocket Probing
The two different pocket depths are:
• Biologic or histologic depth
• Clinical or probing depth

A) Biologic or histologic pocket

depth
B) Probing or clinical pocket
depth
• The biologic depth is the distance between the gingival
margin and the base of the pocket
• The probing depth is the distance to which a probe
penetrates into the pocket
• The depth of penetration of a probe in a pocket depends on
factors such as
size of the probe
force with which it is introduced
 direction of penetration
 resistance of the tissues, and convexity of the crown.
Probe penetration can vary depending on:
• the force of introduction,
• the shape and size of the probe tip and
• the degree of tissue inflammation
 Probing Technique

• The probe should be inserted

parallel to the vertical axis of
the tooth and "walked"
circumferentially around each
surface of each tooth to
detect the areas of deepest
penetration

"Walking" the probe to explore the entire

pocket.
• Special attention should be directed to detecting the presence of
interdental craters and furcation involvements
• To detect an interdental crater, the probe should be placed obliquely
from both the facial and lingual surfaces so as to explore the deepest
point of the pocket located beneath the contact point

Vertical insertion of the probe (left) may not detect interdental craters;
oblique positioning of the probe (right) reaches
the depth of the crater.
• In multirooted teeth the possibility of furcation involvement should
be carefully explored.
• The use of specially designed probes (e.g., Nabers probe) allows an
easier and more accurate exploration of the horizontal component
of furcation lesions

Exploring with a periodontal probe (left) may not detect

furcation involvement; specially designed instruments (Nabers
probe) (right) can enter the furcation area
 LEVEL OF ATTACHMENT VERSUS POCKET DEPTH
• Pocket depth is the distance
between the base of the pocket
and the gingival margin
• It may change from time to time
even in untreated periodontal
disease owing to changes in the
position of the gingival margin, and
therefore it may be unrelated to the
existing attachment of the tooth.
• The level of attachment, on the
other hand, is the distance
between the base of the pocket
and a fixed point on the crown,
such as the
cementoenameljunction.
• Changes in the level of
attachment can be due only to
gain or loss of attachment and
afford a better indication of the
degree of periodontal destruction
 DETERMINING THE LEVEL OF ATTACHMENT

• When the gingival margin is located on the anatomic crown, the

level of attachment is determined by subtracting from the depth of
the pocket the distance from the gingival margin to the
cementoenameljunction. If both are the same, the loss of
attachment is zero

• When the gingival margin coincides with the cementoenamel

junction, the loss of attachment equals the pocket depth
• When the gingival margin is located apical to the cementoenamel
junction, the loss of attachment is greater than the pocket depth,
and therefore the distance between the cementoenameljunction
and the gingival margin should be added to the pocket depth.
Drawing the gingival margin on the chart where pocket depths are
entered helps clarify this important point.
 Bleeding on Probing
• The insertion of a probe to the bottom of the pocket elicits bleeding if
the gingiva is inflamed and the pocket epithelium is atrophic or
ulcerated.

Non inflamed sites rarely bleed.

• In most cases, bleeding on probing is an earlier sign of inflammation

than gingival colour changes.

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

probing.
• Depending on the severity of inflammation, bleeding can vary from
a tenuous red line along the gingival sulcus to profuse bleeding.

• After successful treatment, bleeding on probing ceases .

• To test for bleeding after probing, the probe is carefully introduced

to the bottom of the pocket and gently moved laterally along the
pocket wall.
• Sometimes bleeding appears immediately after removal of the probe ;
other times it may be delayed a few seconds.

• Therefore the clinician should recheck for bleeding 30 to 60 seconds

after probing.

• As a single test, bleeding on probing is not a good predictor of

progressive attachment loss; however its absence is an excellent
predictor of periodontal stability.
• When present in multiple sites of advanced disease , bleeding on
probing is a good indicator of progressive attachment loss.

• Insertion of a soft wooden inter-dental stimulator in the inter-dental

space produces a similar bleeding response and can be used by the
patient to self-examine the gingiva for the presence of inflammation.
When to probe
• Probing of pockets is done at various times for diagnosis, and for
monitoring the course of treatment and maintenance.

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

by the presence of heavy inflammation and abundant calculus and
cannot be done very accurately.
• The purpose of the initial probing, together with the
clinical and radiographic examination is done, however, with the
main purpose of determining whether the tooth can be saved or
should be extracted.
• After the patient has performed an adequate plaque control for
some time and calculus has been removed, the major inflammatory
changes disappears, and a more accurate probing of the pockets
can be performed.
• This second probing is for the purpose of accurately establishing
the level of attachment and degree of involvement of roots and
furcations.

• Data obtained from this probing provides valuable information for

treatment decisions.

• Further along periodontal treatment probings are done to determine

changes in pocket depth and to ascertain healing progress after
different procedures.
 Probing around implants

• Since periimplantitis can create pockets around implants, probing

around them becomes part of examination and diagnosis.

• To prevent scratching of the implant surface, plastic periodontal

probes should be used instead of the usual steel probes used for the
natural dentition.
 Determination of disease activity

• The determination of pocket depth or attachment levels does not

provide information on whether the lesion is in an active or inactive
state.

• Currently there is no sure method to determine activity or inactivity

of a lesion.
 • Inactive lesions may show little or no bleeding on probing and
minimal amounts of gingival fluid; the bacterial flora, as revealed
by dark-field microscopy, consists mostly of coccoid cells.

• Active lesions bleed more readily on probing and have large

amounts of fluid and exudate; their bacterial flora shows a greater
number of spirochetes and motile bacteria
 Amount of attached gingiva

• It is important to establish the relation between the bottom of the

pocket and the muco-gingival line.

• The width of the attached gingiva is the distance between the muco-
gingival junction and the projection on the external surface of the
bottom of the gingival sulcus or the periodontal pocket.

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

because the latter also includes the marginal gingiva
• The width of the attached gingiva is determined by subtracting the sulcus
or pocket depth from the total width of the gingiva (gingival margin to
mucogingival line).

• This is done by stretching the lip or cheek to demarcate the mucogingival

line while the pocket is being probed.

• The amount of attached gingiva is generally considered to be insufficient

when stretching of the lip or cheek induces movement of the free gingival
margin.
 Degree of gingival recession

• Other methods used to determine the amount of attached gingiva include

pushing the adjacent mucosa coronally with a dull instrument or painting
the mucosa with Schiller's potassium iodide solution, which stains keratin.

• During periodontal examination, it is necessary to record the data

regarding the amount of gingival recession.

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

enamel junction to the gingival crest.
 Alveolar bone loss

• Alveolar bone levels are evaluated by clinical and radiographic

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

the architecture of the inter-dental bone.

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

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

• Palpating the oral mucosa in the lateral and apical areas of the
tooth may help locate the origin of radiating pain that the patient
cannot localize.

• Infection deep in the periodontal tissues and the early stages of a

periodontal abscess may also be detected by palpation.
 Suppuration

• The presence of an abundant number of neutrophils in the gingival

fluid transforms it into a purulent exudate.

• Several studies have evaluated the association between

suppuration and the progression of periodontitis and reported that
this sign is present in a very low percentage of sites with the disease
(3 to 5%).
• Therefore it is not by itself a good
indicator.

• Clinically, the presence of pus in a

periodontal pocket is determined by
placing the ball of the index finger
along the lateral aspect of the
marginal gingiva and applying
pressure in a rolling motion toward the
crown
• Visual examination without digital pressure is not enough.

• The purulent exudate is formed in the inner pocket wall, and therefore
the external appearance may give no indication of its presence.

• Pus formation does not occur in all periodontal pockets, but digital
pressure often reveals it in pockets where its presence is not suspected.
 Periodontal abscess

• A periodontal abscess is a localized accumulation of pus within the

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

• The acute periodontal abscess appears as an ovoid elevation of the

gingiva along the lateral aspect of the root.

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

The shape and consistency of the elevated area vary; the area may
be domelike and relatively firm, or pointed and soft.
• In most cases, pus may be expressed from the gingival
margin with gentle digital pressure.

• The acute periodontal abscess is accompanied by

symptoms such as :
-throbbing radiating pain
-exquisite tenderness of the gingiva to palpation
-sensitivity of the tooth to palpation
-tooth mobility
- lymphadenitis
 and, less frequently, systemic effects such as fever,
leukocytosis, and malaise.
• Occasionally, the patient may have symptoms of an acute periodontal
abscess without any notable clinical lesion or radiographic changes.

• The chronic periodontal abscess usually presents a sinus that opens

onto the gingival mucosa somewhere along the length of the root.

• There may be a history of intermittent exudation.

• The orifice of the sinus may appear as a difficult-to-detect pinpoint
opening, which, when probed, reveals a sinus tract deep in the
periodontium.

• The sinus may be covered by a small, pink, beadlike mass of

granulation tissue.

• The chronic periodontal abscess is usually asymptomatic.

• However, the patient may report episodes of dull, gnawing pain; slight
elevation of the tooth; and a desire to bite down on and grind the
tooth.
• The chronic periodontal abscess often undergoes acute
exacerbations with all the associated symptoms.

• Diagnosis of the periodontal abscess requires correlation of the

history and clinical and radiographic findings.

• The suspected area should be probed carefully along the gingival

margin in relation to each tooth surface to detect channel from the
marginal area to the deeper periodontal tissues.
• Continuity of the lesion with the gingival margins is the clinical
evidence that the abscess is periodontal.

• The abscess is not necessarily located on the same surface of the

root as the pocket from which it is formed.

• A pocket at the facial surface may give rise to a periodontal abscess

inter-proximally.
• It is common for a periodontal abscess to be located at a root surface
other than that along which the pocket originated, because drainage is
more likely to be impaired when a pocket follows a tortuous course.

• In children a sinus orifice along the lateral aspect of a root is usually the
result of peri-apical infection of a deciduous tooth.

• In the permanent dentition such an orifice may be caused by a periodontal

abscess, as well as by apical involvement.
• The orifice may be patent and
draining, or it may be closed and
appear as a red, nodular mass.

• Exploration of such masses with a

probe usually reveals a pinpoint
orifice that communicates with an
underlying sinus.
 Sinus

Sinus orifice from a palatal periodontal abscess

A. Pinpoint orifice in the palate indicative of a sinus from a
periodontal abscess.
B. Probe extends into the abscess deep in the periodontium.
 Periodontal abscess VS gingival abscess

• The principal differences between the periodontal abscess and the

gingival abscess are the location and history

• The gingival abscess is confined to the marginal gingiva, and it

often occurs in previously disease-free areas

• It is usually an acute inflammatory response to forcing of foreign

material into the gingiva.

• The periodontal abscess involves the supporting periodontal

structures and generally occurs in the course of chronic destructive
periodontitis.
 Periodontal abscess & periapical abscess

• Several characteristics can be used as guidelines in differentiating a

periodontal abscess from a periapical abscess.

• If the tooth is non-vital, the lesion is most likely periapical.

• However, a previously non-vital tooth can have a deep periodontal

pocket that can abscess.
• Moreover, a deep periodontal pocket can extend to the apex and
cause pulpal involvement and necrosis.

• An apical abscess may spread along the lateral aspect of the root
to the gingival margin.

• However, when the apex and lateral surface of a root are involved
by a single lesion that can be probed directly from the gingival
margin, the lesion is more likely to have originated in a periodontal
abscess.
• Radiographic findings are sometimes helpful in differentiating between
a periodontal and a periapical lesion

• Early acute periodontal and periapical abscesses present no

radiographic changes.

• Ordinarily, a radiolucent area along the lateral surface of the root

suggests the presence of a periodontal abscess, whereas apical
rarefaction suggests a periapical abscess.
 However, acute periodontal abscesses that show no radiographic
changes often cause symptoms in teeth with long-standing,
radiographically detectable periapical lesions that are not contributing
to the patient's complaint.

• Clinical findings, such as the presence of extensive caries, pocket

formation, lack of tooth vitality, and the existence of continuity
between the gingival margin and the abscess area, often prove to be of
greater diagnostic value than radiographic appearance.
• A draining sinus on the lateral aspect of the root suggests
periodontal rather than apical involvement; a sinus from a
periapical lesion is more likely to be located further apically.

• However, sinus location is not conclusive.

• In many instances, particularly in children, the sinus from a

periapical lesion drains on the side of the root rather than at the
apex.
 The Periodontal Screening &RecordingTM
(PSR®)

• PSR system is designed for easier an d faster screening and recording

of the periodontal status of a patient by a general practitioner or a
dental hygienist.

• It uses a specially designed probe that has a 0.5-mm ball tip and is
colour coded from 3.5 to 5.5 mm

• The patient's mouth is divided into six sextants (maxillary right,

anterior, and left; mandibular left, anterior, and right).
• Each tooth is probed, with the clinician
walking the probe around the entire
tooth to examine at least six points
around each tooth: mesio-facial, mid-
facial, disto-facial, and the
corresponding lingual/palatal areas.
• The deepest finding is recorded in
each sextant, along with other
findings, according to the following
code:
• Code 0,
• Code 1,
• Code 2,
• Code 3,
• Code 4.
• Code 0: In the deepest sulcus of
the sextant, the probe's colored
band remains completely
visible. Gingival tissue is
healthy and does not bleed on
gentle probing.

• No calculus or defective
margins are found. These
patients require only
appropriate preventive care.
• Code 1: The colored band of the
probe remains completely
visible in the deepest sulcus of
the sextant; no calculus or
defective margins are found, but
some bleeding after gentle
probing is detected.
• Treatment for these patients
consists of subgingival plaque
removal and appropriate oral
hygiene instructions.
• Code 2: The probe's colored
band is still completely visible,
but there is bleeding on
probing, and supra-gingival or
sub-gingival calculus and/or
defective margins are found.
Treatment should include plaque
and calculus removal, correction
of plaque-retentive margins of
restorations, and oral hygiene
instruction.
• Code 3: The colored band is partially submerged. This indicates the
need for a comprehensive periodontal examination and charting of
the affected sextant to determine the necessary treatment plan.

• If two or more sextants score Code 3, a comprehensive full-mouth

examination and charting is indicated.
Code 4: The colored band completely disappears in the pocket,
indicating a depth greater than 5.5 mm. In this case a comprehensive
full-mouth periodontal examination, charting, and treatment planning
are needed.

• Code *: When any of the following abnormalities are seen, an asterisk

(*) is entered, in addition to the code number:
- furcation involvement,
-tooth mobility,
- mucogingival problem,
- gingival recession extending to the colored band of the probe
(3.5 mm or greater).
• The code finding for each sextant and the date are entered on a sticker
which is placed on the patient's record.

• When unusual gingival or periodontal problems are present and

cannot be explained by local causes, the possibility of contributing
systemic factors must be explored

• The dentist must understand the oral manifestations of systemic

disease so that he or she can question the patient's physician
regarding the type of systemic disturbance that may be involved in
individual cases.
• Numerous laboratory tests aid in the diagnosis of systemic diseases.
Descriptions of the manner in which they are performed and the
interpretation of findings are provided in standard texts on the
subject.

• Tests pertinent to the diagnosis of disturbances often manifested in

the oral cavity are referred to briefly here.
Certain signs and symptoms have been
identified with different nutritional
deficiencies.
• However, many patients with nutritional disease do not exhibit
classic signs of deficiency disorders, and different types of deficiency
produce comparable clinical findings.

• Clinical findings are suggestive, but definitive diagnosis of

nutritional deficiencies and their nature requires the combined
information revealed by the history, clinical and laboratory findings,
and therapeutic trial.
Patients on Special Diets for Medical Reasons

• Patients on low-residue, non detergent diets often develop

gingivitis because the prescribed foods lack cleansing action and
the tendency for plaque and food debris to accumulate on the teeth
is increased.

• Because fibrous foods are contraindicated, special effort is made to

compensate for the soft diet by emphasizing the patient's oral
hygiene procedures.
• Patients on salt-free diets should not be given saline mouthwashes,
nor should they be treated with saline preparations without
consulting their physician.

• Diabetes, gallbladder disease, and hypertension are examples of

conditions in which particular care should be taken to avoid the
prescription of contraindicated food.
 Blood tests

• Analyses of blood smears, red and white

blood cell counts, white blood cell
differential counts, and erythrocyte
sedimentation rates are used to
evaluate the presence of blood
dyscrasias and generalized infections.

• Determination of coagulation time,

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

• They may be useful aids in the

differential diagnosis of certain types of
periodontal diseases.
Refrences

• CARRANZA’S- CLINICAL PERIODONTOLOGY

-Tenth edition
• SOBEN PETER- Community and Preventive Dentistry
• Internet Sources
 Google
 Wikipedia