RECENT DIAGNOSTIC AIDS IN PERIODONTICS

Diagnosis is defined as the correct determination, discriminative estimation logically

understanding of conditions figured out during examination with the help of marks, signs and
characteristics of disease.

Purpose of periodontal diagnostic procedure (according to Armitage GC (1996)) :

1. Screening
2. Diagnosis of specific periodontal disease
3. Identification of sites or subjects at an increased risk of experiencing the progression of
periodontal destruction
4. Treatment planning and
5. Monitoring of therapy.

Conventional techniques involve:

1. Clinical diagnosis made by measuring CAL (Clinical Attachment Loss) or radiographically
by observing loss of alveolar bone

2. Conventional technique identify and quantify current clinical signs of inflammation

3. Provides historical evidence of damage with its extent and severity

Limitation associated with conventional technique :

1. Does not provide cause of the condition
2. No information on patient’s susceptibility to the disease
3. Cannot identify sites with ongoing periodontal destruction or sites in remission
4. Cannot differentiate whether response to therapy is positive or negative

RECENT ADVANCES IN PERIODONTAL DIAGNOSIS

I) GINGIVAL TEMPERATURE : Kung et al (1990) claim that thermal probes are sensitive
diagnostic devices for measuring early inflammatory changes in gingival tissue.

i) Subgingival temperature at diseased sites is increased as compared to normal ,

ii) Commercially available system PerioTemp probe enables the calculation of
temperature differential (with sensitivity of 0.10C) between the probed pocket and
subgingival temperature.
iii) Increased cellular and molecular activity caused by increased periodontal
inflammation is the probable cause for the rise In temperature
iv) Elevated subgingival temperature is related to attachment loss
 II) PERIODONTAL PROBING : most widely used diagnostic tool and it is measured from
the free gingival margin to the depth of the probable crevice , it is the gold standard
for recording changes in periodontal status

Limitation of a conventional probing include :

 Lack of sensitivity and reproducibility.
 Disparity between measurement depends on: probing technique, probing force, angle of
insertion of probe, size of probe, precision of calibration, presence of inflammation.
 Readings of clinical pocket depth measured with probe does not coincide with the
histologic pocket depth.
 All these variable contribute to the large standard deviations (0.5-1.3 mm) in clinical
probing results

CLASSIFICATION OF PERIODONTAL PROBE

1) FIRST GENERATION (Conventional probe):

 Conventional manual probes that do not control probing force or pressure and that are
not suited for automatic data collection.
 Example: Williams periodontal probe , UNC-15 probe , CPITN probe , goldman Fox
probe

2) SECOND GENERATION (Constant force probe) :

 Force To Probe Pocket: 30g
 Force To Probe Osseous Defect: 50g
 Introduction Of Constant Force Or Pressure Sensitive Probes Allowed For Improved
Standardization Of Probing.
 Example: Pressure sensitive probe Constant pressure probe
 Limitation: data readout and storage is inaccurate.

3) THIRD GENERATION (Automated Probe):

 Computer assisted direct data capture was an important step in reducing examiner bias
and also allowed for generation of probe precision. (according to NIDCR criteria)
 Example: Toronto probe, Florida probe, Interprobe, Foster Miller probe.

i) Florida probe:
 Tip is 0.4mm
 Sleeve- edge provides reference to make measurements
 Coil Spring; provides constant probing force
 Computer for data storage.
Probe Handpiece tip enters the sulcus with constant force in use (tip at bottom of sulcus) and
sleeve properly positioned at the top of the gingival margin allowing the computer to measure
the difference.
Limitations :

 Lack of tactile sensitivity

 Fixed probing force
 Underestimation of deep periodontal pockets.

4) FOURTH GENERATION (Three dimensional Probe):

• Currently under development, these are aimed at recording sequential probe positions
along a gingival sulcus.
• An attempt to extend linear probing in a serial manner to take account of the continuous
and three dimensional pocket that is being examined.

5) FIFTH GENERATION (3D and Non invasive):

 Basically these will add an ultrasound to a fourth generation probes.
 If the fourth generation can be made, it will aim in addition to identify the attachment
level without penetrating it.
 Example: Ultra sonographic probe.

ADVANCES IN RADIOGRAPHIC ASSESSMENT

Dental Radiographs are traditional method to assess destruction of alveolar bone.

“Conventional radiographs are very specific but lack sensitivity”
Primary criterion for bone loss is the distance from CEJ to the alveolar crest and distance more
than 2 mm is considered as the bone loss.
But variability affecting conventional radiographic technique are :
 Variation in projection geometry
 Variation in contrast and density
 Masking by other anatomic structures.

1) Digital radiography
 Capturing radiographic image using a sensor
 Advantages
1. Elimination of chemical processing
2. Increased efficiency and speed of viewing
3. Diagnostic information can be enhanced
4. Computerized storage of radiographs
5. Reduced exposure to the radiation

2) Subtraction radiography
 This is a technique by which images not of diagnostic value in a radiograph, are
eliminated so that changes in the radiograph can be precisely detected
 Serial radiographs converted to digital images superimposed
  This technique requires a paralleling technique to obtain a standardize geometry
and accurate superimposable radiographs
 This technique facilitates both quantitative and qualitative visualization of even
minor density changes in the bone
 Increased detectability of small osseous lesions by subtraction method compared
with conventional radiography
 Recent image subtraction:“diagnostic subtraction radiography” (DSR) Modification
Use of a positioning device during film exposure

3) Computed tomography (CT)

 Fan shaped X-ray source is used
 The computed tomographic image is reconstructed by computer, which mathematically
manipulates data obtained from multiple projections.
 Computed tomography is a specialized radiographic technique that allows visualization
of planes or slices of interest
 Eliminates superimposition
 inherent high contrast resolution aids in , distinguishing between tissues that differ in
physical density by less than 1%.
 multiple scans of a patient may be viewed as images in the axial, coronal, or sagittal
planes depending on the diagnostic task, referred to as multiplanar imaging.
 Application of CT
 Used when accurate information regarding the topography of osseous structure is
needed
 Soft tissue contour and dimension
 To check continuity and density of the cortical plates
 vertical height of the residual alveolar ridges
 density of the medullary space and basilar bone
 Disadvantages CT
specialized equipment and setting.
 Radiologists and Technicians need to be knowledgeable of the anatomy, anatomic
variants and pathology of the jaws
 higher radiation
 Metallic Restorations can cause ring artifacts that impair the diagnostic quality of the
image

4) Cone-beam Computed Tomography (CBCT)

 For acquiring 3D images of oral structures
 It is cheaper than CT, less bulky and generates low dosages of X- radiations.
 The innovative CBCT machine designed for head and neck imaging are comparable in
size with an orthopantomogram.
 Advantages
 It gives complete 3D reconstruction
  CBCT units reconstruct the projection data to provide interrelational images in three
orthogonal planes (axial, sagittal, and coronal).
 Its beam collimation enables limitation of X-radiation to the area of interest.
 Patient radiation dose is five times lower than normal CT, as the exposure time is
approximately 18 seconds, that is, one-seventh the amount compared with the
conventional medical CT.
 Reduced image artefacts
 Evaluation of the jaw bones which includes the following:
 Bony and soft tissue lesions
 Periodontal assessment
 Soft tissue CBCT for the measurement of gingival tissue and the dimensions of the
dento gingival unit
 alveolar bone density measurement
 Temporomandibular joint evaluation

MICROBIOLOGICAL ANALYSIS

1. support diagnosis of various Periodontal disease

2. Can tell about initiation & progression
3. To determine which periodontal sites are at high risk for active destruction
4. Can also be used to monitor Periodontal therapy

Immunodiagnostic methods
Immunological assays use fluorescent conjugated antibodies that recognize specific
bacterial antigens, and the identification of these specific antigen-antibody reactions
allows the detection of target microorganisms.
This reaction can be visualized using a variety of techniques and reactions:
1. Direct (DFA) and indirect (IFA) immunofluorescent assays
2. Flow cytometry
3. Enzyme-linked immunosorbent assay (ELISA)
4. Latex agglutination

1) Immunofluorescent assay

Mainly used to detect A. a. and P.g.

2) Enzymatic methods
 Some periodontal pathogens release a trypsin like enzyme which when reacted
with BANA (N-benzoyl-d L-arginine-2-naphthylamide) undergoes hydrolysis
 Beta- naphthylamide (chromophore) is the end product
 Perioscan uses this reaction for the identification of the bacterial profile in plaque
sample
  Detection of these pariodontal pathogens by BANA reaction serves as a marker of
disease activity
 shallow pockets exhibited 10% positive BANA reaction, whereas deep pockets
(7mm) exhibited 80%-90% +ve BANA reaction
 Beck et al. (1995) used BANA test as a risk indicator for periodontal attachment loss
 Disadvantage includes:
 May be positive in clinically healthy site
 Can not detect sites undergoing periodontal destruction
 Limited organisms detected

3) Flow cytometry
 Rapid identification
 Principle is labelling bacterial cells with both species-specific antibody and a second
fluorescein-conjugated antibody
 This suspension is introduced into flow cytometer, which separates bacterial cells
into an almost single cell suspension
 Limitation is sophistication and cost involved with this procedure

4) ELISA
 To detect serum antibodies to periodontal pathogens.
 In research studies to quantify specific pathogens in subgingival sample
 Quantitative analysis

MOLECULAR BIOLOGY TECHNOLOGY

The principles of molecular biology technique reside in the analysis of DNA, RNA and the
structure and function of proteins
Diagnostic assays require specific DNA fragment (DNA Probe) that recognize complementary-
specific DNA sequences from target microorganisms
This technology requires bacterial DNA extracted from the plaque sample and amplification of
the specific DNA sequence of the target pathogen

1) Polymerase chain reaction (PCR)

 Repeated cycles of oligonucleotide (primer)–directed DNA synthesis of “target
sequences” are carried out in vitro.
 The PCR method is considered the fastest and most sensitive method available for
detecting the presence of bacterial DNA sequences
 A modification of the original PCR technology, "real- time" PCR, permits not only
detection of specific microorganisms in plaque, but also its quantification.
 Advantages
1. High detection limit. As less as 5- 10 cells can be amplified and detected.
2. Less cross reactivity under optimal conditions
 3. Many species can be detected simultaneously
 Disadvantage
1. Small quantity needed for reaction may not contain the necessary target DNA
2. Plaque may contain enzymes which may inhibit these reactions.

Future application of advanced diagnostic techniques will be of value as an adjunctive in

documenting disease activity and treatment options. But, despite excellent progress in
diagnostic methodology, conventional efforts evaluating inflammation and past evidence of
tissue breakdown remain the standard for disease evaluation