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PERIODONTOLOGY

Tutorial 1
Introduction to Periodontal
Examination
Dr C Gonzales-Marin
c.gonzalesmarin@qmul.ac.uk

Learning Outcomes
You should be able to:
Discuss the scores of the BPE and the related indication for
treatment
Recognise when to carry out a full-mouth periodontal
examination based on the BPE scores
Describe step-by-step how to complete a full-mouth
periodontal examination
Correctly identify anatomical references to measure probing
depth, recession and clinical attachment loss
Describe the classification for tooth mobility and furcation
and how to record this in a full-mouth periodontal chart
Cont

nd
2 Part
Discuss the role of a full-mouth periodontal chart to help
determine the correct diagnosis in conjunction with the
patients history, risk factors for periodontal disease and
radiograph
Discuss the importance of monitoring plaque and
bleeding scores as part of the periodontal treatment
Discuss the aims of a review session and making
arrangements for appropriate recall time

(WILL BE DELIVERED LATER THIS YEAR)

RECAP from Transition 4:


History and Examination

The Periodontal Patient

HISTORY TAKING
COMPLAINT OF
HISTORY OF PRESENT
COMPLAINT
MEDICAL HISTORY
SOCIAL HISTORY
PAST DENTAL HISTORY

EXAMINATION

EXTRAORAL EXAM
INTRAORAL EXAM
Soft tissues: description
Hard tissues: charting/
occlusion
Periodontal tissues: gingival
characteristics, OH, BPE

DIFERENTIAL DIAGNOSIS
SPECIAL INVESTIGATIONS:
Radiographs, full mouth
periodontal chart, vitality
test and palpation (ENDO),
impressions (PROS), baseline
plaque and bleeding scores
DEFINITIVE DIAGNOSIS
PROGNOSIS
TREATMENT PLANNING
(Em.; Stabiliz.+Review; Rest.)

FOLLOW-UP (Maintenance Phase)


RECALL

H&E: Assess Periodontal Health


and Oral Hygiene Behavior
Aetiology of Periodontal Disease: Infection (plaque)
Pathophysiology: Inflammatory/Immune Reaction

by taking relevant history,


performing clinical examination
results from special test (probing, mobility, radiographs, etc)
recording and monitoring dental plaque

D&T:
Periodontal Diagnosis Periodontal Treatment Review
Periodontal Maintenance RECALL

Most Common Periodontal C/O


C/O + HPC
Check- up (Perio Disease no signs or symptoms)
Bleeding gums
- Is it bleeding on brushing? Is it spontaneous?
- When it started?
- Do you feel any mobility? Is it increasing?
- Do you notice any bad breath or bad taste?
- Did you notice that your gums are pulled away?
Gum recession
- When did it started?
- Do you have any sensitivity?
- How often do you brush your teeth?
- Review brushing technique
- Did you have orthodontic treatment before? (braces)
- Any bleeding on brushing/mobility?

Mobile teeth

When this was noticed first?


Is it increasing?
Any specific tooth, more than one? Which ones?
Change in position?
Any bad breath or bad taste?
Pain?
Any diagnostic of periodontal disease?
Any previous treatment? By who? When? What treatment?
Does this prevent you from eating?

Discuss Patients Expectations

Patients needs and desires for treatment


Expectations for treatment outcome aesthetics may be compromised
Patients demands may not be congruent
COMMUNICATION is important
Specialist referral?

Medical History and Perio


Some systemic diseases, conditions or behavioural factors may play a
role in the cause of the disease
The presence of conditions may require special precautions or
modification of treatment
Oral infections may have an influence on occurrence and severity of
systemic diseases
Check for:

Bleeding disorders: Anaemia


Liver disease. eg. cirrhosis, impaired coagulation
Diabetes. Increased risk factor for PD
Cardiovascular diseases, HBP medication?
Drug-induced gingival hyperplasia:
calcium channel blockers: amlodipine, nifedipine
Anticonvulsants (epilepsy): phenytoin
Immunosuppressant: cyclosporine

Hormone-related conditions and Pregnancy


Allergies

Social History and Perio


Priorities and attitude to dental care
Availability for treatment
Problems attending many appointments, lengthy
appointments

SMOKING
Cigarette smoking is the 2nd most important Risk
Factor in periodontal disease.
Exposure time and quantity
When, How many, How long?

Family History and Perio


Family history of periodontitis (Aggressive
Periodontitis)

Past Dental History and Perio


Signs and symptoms of periodontitis noted by the patient:
Tooth migration
Increasing mobility of the teeth
Bleeding gums
Food impaction
Difficulties in chewing
Frequency and duration of daily toothbrushing
Knowledge about interdental cleansing and use of
mouthwash
Previous periodontal treatment and maintenance
Use of prosthesis or need for one
Previous or current orthodontic treatment

INTRAORAL
EXAMINATION
What is periodontal
health?
Disease

Health

Healthy Gingival Tissues

Describe gingiva
Systematic approach
1. Colour
2. Size
3. Shape
4. Contour
5. Consistency
6. Surface texture
7. Position

* Transition 4_ Tutorial 1

Localized, diffuse, intensely red area facial of UR2 and darkpink marginal changes in remaining anterior teeth

Generalized diffuse gingivitis involves the


marginal, papillary, and attached gingivae

Discoloration of the gingiva caused by embedded


metal particles (amalgam)

Gingival inflammation and enlargement associated with


orthodontic appliance and poor oral hygiene

Gingival enlargement associated with phenytoin therapy. Note the


prominent papillary lesions and the firm, nodular surface

Twelve-year-old female with a primary medical diagnosis of


leukaemia that exhibits swollen/spongy gingiva

Clinical image of plaque-related moderate chronic


periodontitis with 3 to 4 mm clinical attachment loss in
53-year-old male smoker

Gingivitis
vs
Periodontitis

Screening for Periodontal


Disease

BPE
Score

Disease

Treatment

No disease

No need

Bleeding

OHI

Plaque retentive OHI, remove


factors

Pocket >3.5

OHI, RSD

Pocket >5.5

OHI, RSD,
assess need
complex tx,
referral?

Furcation

=4

WHEN DO WE NEED TO COMPLETE A 6PPC?

BPE test in LAB!


(next week)

Full-mouth Periodontal chart


or 6-Points-Pocket-Chart
To register
parameters of
Periodontal
Disease

To diagnose, determine severity,


extension, treatment success
Medico-legal
document

Periodontal Attachment System


in Health
GINGIVA

PERIODONTAL
LIGAMENT
CEMENTUM
ALVEOLAR
BONE

Periodontal Attachment System


in Disease
Loss of attachment (LOA) is
damage to the structures that
support the tooth.

1. Relocation of the junctional


epithelium
2. Destruction of gingival fibers
3. Destruction of periodontal
ligament
4. Loss of alveolar bone support

Position of the Gingival Margin


In periodontitis, the
gingival margin may
remain near the CEJ.
This creates a deep
periodontal pocket.

Recession of Gingival Margin


Gingival margin has
receded and tooth roots
are visible

The gingiva can mask bone loss

What to register in the 6PPC?


Teeth not present
Probing depth at 6 sites/tooth
Recession
*Clinical Attachment Loss
Mobility
Furcation
Bleeding on probing (6 sites)

CONCEPT 1: Probing Depth


[also called pocket depth]
The distance in
millimeters from the
gingival margin to the
base of the sulcus or
periodontal pocket as
measured with a probe

Measurements Recorded

Measurements are
recorded for six specific
sites on each tooth.

FOR PROBING DEPTH


FOR RECESION
FOR BLEEDING ON PROBING

Record the Deepest


Measurement
In this example, the
deepest reading would be
recorded for the facial
reading (yellow shade in
previous slide).
That reading is the one
taken at point C.

Remember Walking Technique

INTERPROXIMAL
READINGS

Limitations of Measurements
Various factors can affect accuracy and
repeatability of measurements:
Position of gingival margin
Interference from calculus deposits,
overhanging restorations
Amount of pressure applied
Misread probe calibrations
Probe position in healthy and diseased
pockets

CONCEPT 2: Recession
Measurement of the Gingival margin
(GM-CEJ)

Recession

Recession ?

1. Margin Slightly Coronal to CEJ


The natural position of the
gingival margin in health

2. Margin Apical to CEJ


Seen on these three
anterior teeth
Termed recession
Common in periodontitis

3. Margin Covers CEJ


The gingival margin
significantly covers CEJ
Commonly seen in
gingivitis caused by
medications (Gingival
hyperplasia)

Recording Positive(+) or
Negative (-)
When recording recession of the gingival margin, think:
How much gingival tissue would be added (+) to return
margin to normal position?
When recording gingival margin that covers CEJ, think:
How much gingival tissue would be taken away (-) to return
margin to normal position?

Example: Mr Smith

CONCEPT 3: Clinical Attachment Loss


How
much
bone
loss?

Measurement CAL = base pocket-CEJ


OR CAL= Probing depth + Recession

IF EACH BAND OF THE


PROBE MEASSURES 2mm

Tooth A
What is the probing
depth?
What is the GM-CEJ
distance?
What is the CAL?

Tooth B
What is the probing
depth?
What is the GM-CEJ
distance?
What is the CAL?

Tooth C
What is the probing
depth?
What is the GM-CEJ
distance?
What is the CAL?

Bleeding
score

vs.

Bleeding
on probing

Recorded as part of the 6PPC during probing


Bleeding score is a measurement
Measure presence of inflammatory lesions located
of inflammation at gingival margin
at the base of the periodontal pocket
It relates to the oral hygiene
Insertion of probe elicits bleeding if gingiva is
status of the patient
inflamed and the pocket epithelium is atrophic
Ideal for OH control and
or ulcerated.
monitoring in long-term
Red dot on top of PD measurement (at 6 sites/tooth)

Mobility- technique

Classification of Mobility
Class 1

Slight mobility, up to 1 mm of horizontal


displacement in a facial-lingual direction

Class 2

Greater than 1 mm but less than 2mm of


horizontal displacement in a facial-lingual
direction

Class 3

Greater than 2 mm of horizontal displacement


in a facial-lingual direction or vertical mobility

Furcation

Furcation Anatomy
Furcation entrance and where
to measure from

Nabers Probe

Rating furcation involvement

3
OBS: Consider that 1st clear band
of Nabers probe measures 3mm

Full-Mouth Periodontal
Examination (6PPC)
Step-by-step

Highlight or circle the POCKETS, or use a colour code to help understanding the problem
In the example: Mild= yellow (4mm) Moderate = pink (5-6mm) Severe= orange (7+)

Name of the patient

v
5 date

123

4 ...
3 date 123
6 date

. .

123

123

456 789

No mobility [or]

date
date
date

Highlight the
pockets

PRACTICAL
FMPC - Lab1/Clinic1
Learning Outcomes
By the end of the session you should be able to:
Demonstrate the correct use of a Williams probe to measure
the probing depth at 6 sites around each tooth
Identify factors that can affect the accuracy of periodontal
probing
Demonstrate the technique for assessing tooth mobility and
furcation
Demonstrate how to describe and interpret the information
collected through a full-mouth periodontal examination
Perform a full-mouth periodontal examination in your clinical
partner

Bring your handbook!


Lab 1: Full-Mouth Periodontal Chart
WHEN: 8th and 12th December
MON 1-3pm/MON 3-5pm/FRI 9-11am/FRI 11-1pm
WHERE: LABORATORY 3rd Floor
2 hour session/ 2 groups/ 2 tutors

Individually:
Sign attendance, log-in to QMplus tutorial, prepare your bay (15 min)
BPE Exam (10 minutes)
Self-Assessment Form: Full-Mouth Periodontal Chart (60min)

BPE
Williams probe
Full-Mouth Periodontal Chart
Clinical Attachment Loss
Tooth mobility
Furcation Involvement

Clear-up your bays (10min)


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