Periodontal Disease and the Periodontal Examination

• Periodontitis - main features:

  • Onset and progression often occur in the absence of pain
  • A 'silent' disease (may not experience any symptoms)
  • Highlights the importance of regular examinations
  • Prevention is critically important
  • Erythema and swelling of the gingival tissues can be seen in periodontitis, like with gingivitis
  • But unlike with gingivitis, periodontitis involves pocket formation

  
• Clinical features of periodontitis:

  • Pocket formation
  • Bleeding on probing
  • Alveolar bone resorption
  • Tooth mobility
  • Halitosis
  • Tooth loss
• Probing can be used to detect periodontal pockets. With periodontal pockets the pocket depth increases, there's a loss of periodontal support and alveolar bone support as time goes on.

  
• Clinical features of periodontitis - pocket formation:

  • Periodontal pocket - a pathologically deepened sulcus
  • Loss of attachment from the periodontal supporting tissues & tooth surface
  • True pockets - result from apical migration of the junctional epithelium following loss of connective tissue attachment to the root surface
  • False pockets - result from gingival enlargement with no alteration in the position of the junctional epithelium
  • Suprabony pockets - junctional epithelium coronal to the alveolar crest
  • Infrabony pockets - junctional epithelium extends apically beyond the alveolar crest
• Clinical features of periodontitis - bleeding on probing:

  • Indicator of inflammation (which occurs in response to presence of dental plaque microorganisms in plaque biofilm)
  • Bleeding on probing occurs at inflamed sites where thin and ulcerated junctional and pocket epithelia are penetrated by the probe tip
• Clinical features of periodontitis - alveolar bone resorption:

  • Occurs concurrently with attachment loss and pocket formation
  • Horizontal bone loss - occurs when the entire width of interdental bone is resorbed
  • Vertical bone loss - occurs when the interdental bone adjacent to the root surface is more rapidly resorbed - an angular, more uneven morphology
• Clinical features of periodontitis - tooth mobility:

  • Physiological mobility - allows slight tooth movements in socket to accommodate masticatory forces, without injury to tooth/supporting tissues
  • Pathological mobility - increased/increasing mobility due to connective tissue attachment loss - extent depends on bone support, degree of inflammation in PDL & gingiva, & magnitude of forces that may act on teeth
  • Migration of teeth - can occur as a result of attachment loss/gingival overgrowth - frequently maxillary incisors drift labially (increased overjet) - teeth also tend to over-erupt
• Recession could be localised (in some patients could be caused by toothbrush trauma, or anatomical factors). Generalised recession, where the gingival margin migrates apically, could by caused by ongoing progression of periodontal disease. If periodontitis is treated to try to resolve inflammation, recession could also result as a result of this (may experience it as part of the healing process). A pt with is treated to try to resolve inflammation, recession could also result as a result of this (may experience it as part of the healing process).

  
• Suppuration can occur from the periodontal pocket, with an oozing of pus around the gingival margin. If pus is able to escape through the periodontal pockets, then it's self-limiting, to a degree. But if the pus becomes less able to escape, or if there's another acute exacerbation of the periodontal pocket, this could lead to swelling, which could lead to an acute periodontal abscess (an acute suppurative inflammatory lesion within the periodontal pocket). So periodontal abscesses can occur as a result of progressive periodontitis.

  
• Clinical features of periodontitis:

  • Halitosis
  • Could be a result of plaque build-up/plaque stagnation around restoration/crown margins - but could also be a result of periodontitis
  • Gram-negative bacteria and periodontal pathogens in subgingival biofilm
  • Production of volatile sulphur compounds
  • Common intra-oral sources of halitosis = periodontal pockets (as a result of the anaerobic bacteria in this environment) and crypts on the surface of the tongue (can harbour anaerobic bacteria)
  • Tooth loss - result of periodontitis if not treated
• Presenting complaints and symptoms of periodontitis reported by pts:

  • Bleeding gums
  • Teeth changed position/drifting teeth
  • Over-erupted teeth
  • Mobile teeth
  • Bad breath
  • Bad taste
  • Gum swelling
  • Localised pain
• History in the periodontal examination:

  • Presenting complaint
  • Bleeding gums, mobility, receding gums, bad breath, pain
  • Reason for attendance
  • HPC
  • Concerns/anxieties
  • Info on pt motivation
  • MH: diabetes, medication, rheumatoid arthritis/osteoarthritis, cardiovascular disease, stress, immunosuppression
  • SH: smoking, alcohol, occupation, stress
  • Family history (of periodontitis)
  • Dental history:
  • What treatment and when
  • Frequency of attendance
  • History of dental treatment
  • Experience of dental treatment
• Identify risk factors for periodontitis:

  • A thorough history should enable identification of risk factors
  • Assess risk factors
  • Impact of risk factors on prognosis
  • Address risk factors
  • Explain risk factors for periodontal diseases to patients
• Clinical observations in periodontitis:

  • Oral hygiene
  • Plaque levels
  • Gingival inflammation (erythema, swelling)
  • Bleeding from soft tissues
  • Calculus
  • Mobility and drifting of teeth
  • Missing teeth
  • Suppuration or swelling
  • Abscess formation
  • Gingival recession
  • Furcation involvement
• Basic Periodontal Examination (BPE):

  • The most basic, initial examination of the periodontium
  • Should be completed for all new patients
  • It's a screening tool only - not used to diagnose periodontal disease
  • Dentition divided into sextants
  • WHO probed walked around sulcus
  • Highest score recorded for each sextant
  • A light probing force of 25g, equivalent to the force required to blanch a fingernail, is used when probing the periodontal tissues
• Basic Periodontal Examination (BPE):

  • The 8s are not included (unless 1st and/or 2nd molars are missing)
  • Each sextant must have 2 or more teeth to complete a BPE score
  • If a sextant only has 1 tooth, include tooth with adjacent sextant
  • BPE is not suitable for examination of implants (record 4 or 6 point chart instead)
  • Number and * recorded if furcation involvement
• Basic Periodontal Examination (BPE):

  • For codes 0, 1 & 2 BPE should be repeated in every exam appointment
  • For codes 3 & 4, more detailed periodontal charting is required - periodontal assessment
  • BPE scores of 3/4 require further periodontal assessment
  • If BPE score of 4 in any sextant OR evidence of interdental recession -> full mouth periodontal assessment
  • If BPE score of 3 in any sextant:
  • Step 1 therapy - OHI, Professional Mechanical Plaque Removal (PMPR), risk factor management
  • Re-evaluate after Step 1 therapy - review - localised periodontal charting & assessment in affected sextants
• Full periodontal assesment - the components of a periodontal assessment are:

  • Assessment of oral hygiene/engagement with advice
  • Radiographs
  • Six point pocket chart (probing pocket depths - PPDs)
  • Six point bleeding on probing assessment
  • Assessment of mobility
  • Furcation assessment
  • Assessment of recession (in some cases)
• Plaque score:

  • Assessment of plaque levels
  • Assists with identification and explanation of risk factors
  • Useful for patient motivation
• Pocket depths:

  • Base of pocket to gingival margin
  • Recorded in millimetres
  • Measure 6 sites per tooth
  • BSP recommends documenting 4mm+ sites only
  • At NDH we recommend documenting all measurements

  
• Probes for measuring pocket depths:

  • UNC probe has dark bands between 4-5mm, 9-10mm and 14-15mm.
  • Both have mm measurements up the length of the probe.
  • Williams probe: 1-3mm, then jumps to 5mm, and then jumps to 7mm with no black bands

  
• Bleeding on probing:

  • Grading = bleeding is present or absent
  • Indicator for active periodontal disease - absence would suggest an inactivity/stability of periodontitis, or gingival health
• Tooth mobility is assessed and graded:

  • 0 = physiological mobility (<0.2mm) 
  • I = 0.2mm-1.0mm horizontal movement
  • II = >1.0mm horizontal but no vertical movement
  • III = >2.0mm horizontal mobility and/or vertical mobility
• Horizontal tooth mobility is measured by applying a gentle pressure in a buccal-lingual/buccal-palatal direction using an instrument handle or the tip of a burnisher/plugger to see if there's any lateral displacement of the tooth. Vertical mobility can be measured by applying gentle pressure on the crown of the tooth with a rigid instrument handle in a vertical direction.
• Furcation lesions:

  • Class 1: furcation defect <3mm deep
  • Class 2: furcation defect >=3mm deep but not through and through
  • Class 3: furcation defect involves entire width of the furcation - 'through and through' lesion
• Recession:

  • Measured from CEJ to gingival margin
  • According to the 2017 classification, recession can be classified as recession type 1/2/3
  • Recession type 1: gingival recession w/ no loss of interproximal attachment. Interproximal CEJ is clinically not detectable at both mesial & distal aspects of tooth
  • Type 2: gingival recession associated w/ loss of interproximal attachment. The amount of interproximal attachment loss is <= the buccal attachment.
  • Type 3: gingival recession associated w/ loss of interproximal attachment. Amount of interproximal attachment loss is <= the buccal attachment.
• Clinical attachment loss (CAL):

  • Clinical attachment loss (CAL) is how far the junctional epithelium has moved down the root of the tooth
  • CAL = CEJ to base of pocket
  • CAL is different to the probing pocket depth
  • For a case with recession, to work out the CAL we would add the recession measurement to the pocket depth measurement.

  
• Radiographs:

  • When you should take radiographs for perio pts depends on the clinical presentation and indication
  • Radiographs are recommended for all BPE code 3, 4 and * sextants, or where obvious evidence of interdental recession is present

  
• Types of radiographs to take to assess perio:

  • Need to consider - clinical presentation, patient, dosage, quality of image required, area to visualise
  • Periapical radiographs
  • Full mouth assessment
  • DPT or DPT with supplemental PAs or consider full mouth periapicals

  
• From a medico-legal standpoint, it is important to record in the patient's clinical record a thorough assessment of any radiographs. From a periodontal perspective this will include:

  • The degree of bone loss - if the apex is visible this should be recorded as a percentage
  • The type of bone loss - horizontal or angular infrabony defects
  • The presence of any furcation defects
  • The presence of sub-gingival calculus
  • Other features including endo-perio lesions, widened periodontal ligament spaces, abnormal root length or morphology, overhanging restorations, caries

  
• The components of a periodontal assessment are:

  • Assessments of oral hygiene/engagement with advice
  • Radiographs
  • 6 point pocket chart (probing pocket depths - PPDs) - six point bleeding on probing assessment
  • Assessment of mobility
  • Furcation assessment
  • Assessment of recession