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Periodontal Examination

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Margit Strobl

on 17 November 2017

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Transcript of Periodontal Examination

Periodontal Assessement
Maui beach flowers
What is a periodontal assessment?
What are the components of a periodontal assessment?
Yeah! another case study
John is a new patient in your office. His health history indicates he has high blood pressure and when you check it as part of the vital signs you get a reading of 162/ 100.

What do you do next?
Is it safe to treat John?
What should you do for future appointments?

It is now safe to continue John’s treatment. During the Oral exam the following items were noted: bilateral mand tori, fordyce granules, a dark brown, slightly elevated solid mass with well defined borders adjacent to the commissure of the left lip, multiple chicken pox scars and leukoplakia along the midline of the buccal mucosa.
Are these findings significant?
If so, all or some?
What type of follow up is required?

John presents with moderate supragingival calculus on the lingual of the lower anteriors and generalized light interproximal calculus all other areas. John’s probe depths are up to 4mm in depth and the tissue is fairly knife edged.

What type of instruments would you use in the lower anterior area (include detection instruments)?
What type of instruments would you use in the interproximal areas?
What factors would you need to consider when choosing an instrument?

Let's review- healthy tissue

Dark pigmentation to light pink depending on individual (degree of vascularity can also affect color)
Attached gingiva is resilient and firm, tightly bound to underlying bone
Attached gingiva is usually stippled
Gingival margin or gingival crest is located 1 to 2 mm above CEJ
Free gingiva adapts closely to the contours of the teeth
Free gingival groove may be visible
What about bone levels?

Class activities

charting periodontal findings
developing a periodontal diagnostic statement using the AAP
1. Explain the purpose of a periodontal assessment and relate which areas of the periodontium are assessed
2. Explain clinical manifestations associated with inflammation
3. Describe the terms used to identify different types of “pockets”
4. Define furcation involvement and apply the methods of measuring furcation areas in a clinical setting
5.Describe and apply the technique for determining mobility
6. Describe the radiographic appearance of periodontal involvement (bone levels, furcation involvement)
7. Describe and identify mucogingival involvement (mcgi)
8. Explain and demonstrate the calculation of clinical attachment levels
9. Describe systematic sequences for assessing the periodontium and the importance to quality of care
10. Explain the AAP guidelines and how they support the periodontal diagnostic statement
11. Use appropriate charting symbols to “identify” corresponding periodontal clinical conditions and apply accurate documentation principles
12. Describe and apply Periodontal Screening and Recording (PSR) procedures in a clinical setting

In order to effectively and accurately complete a periodontal examination, you need to:
1. have knowledge of anatomy of periodontal tissues
2. be able to recognize normal healthy periodontal tissue
3. recognize basic signs of gingival & periodontal diseases and severity
4. describe and document findings
an evaluation of the teeth, gingiva, amount of plaque biofilm, bone structure, occlusion and risk factors
probing record, mobility, furcation involvement, recession, clinical attachment levels, gingival assessment, and deposit
What is the purpose of completing a periodontal assessment?
establish the client's oral health status
recognize and identify pathological changes in the periodontium in order to plan for appropriate and individualized dental hygiene care
identify and assess risk factors affecting periodontal disease and health maintenance
What equipment is needed?
a good light, air to dry teeth, mouth mirror, explorer, probe and a good set of radiographs
The crest of bone in health should be within 2 mm of CEJ
Will vary in size and shape depending on tooth position
Darby Walsh has a nice table that describes gingival characteristics in health and disease on p 324
Statistics on periodontal disease
US: 47.2% of adults 30 and older have some form of periodontal disease
70.1% of adults 65 and older have periodontal disease (increases with age)
more common in men than women (56.4 vs 38.4%)
those living below poverty level experience 65.4% periodontal disease
those with less than a high school education experience 66.9% rate of periodontal disease
smokers, 64.2% prevalence
Periodontal Disease
Two types: gingivitis and periodontitis
inflammation limited to the gingiva without clinical connective tissue attachment loss or bone loss
No apical migration of the JE
Most forms are plaque-induced but systemic factors may also play a role
loss of clinical attachment and alveolar bone with the formation of a periodontal pocket
Inflammation of supporting tissues of the teeth
Apical migration of the JE
Many forms/etiologies
Clinical manifestations of inflammation
Changes in tissue color
Bleeding on probing
Swelling or edema
(contour, consistency)
Presence of exudate
Texture changes
Erythema or reddened gingiva indicates an increase in the vascularity as a result of the immune response
Bright red indicates an acute inflammation
Blue or purple (cyanosis) indicates venous congestion as a result of chronic inflammation
Bleeding upon probing
one of the earliest signs of inflammation
due to increased vascularity and ulcerated sulcular epithelium
identifies clients at risk for PD progression but not always a predictor of attachment loss
chronically inflammed fibrotic tissue may not bleed
Swelling or Edema
Due to increased permeability of blood vessels in CT
Accumulation of lymphocytes, plasma cells, and extracellular fluid in CT
May result in a gingival pocket or pseudo-pocket where there is swelling of the gingiva but no apical migration of the JE (marginal gingiva moves coronally)
Contour and Texture
Swelling and edema produce changes in texture and contour
Surface of swollen tissue is smooth and shiny with loss of stippling
Marginal gingiva becomes rounded or rolled and loosely adapted to the tooth
Fibrosis may occur in chronic gingivitis
Interdental papillary changes
When col area is inflamed, degeneration of the epithelial and CT layer may result in blunted, split, or cratered papilla
GCF or sulcular fluid increases in the presence of inflammation
Called suppuration when it is a clear serous liquid and purulent exudate when it contains PMN’s, necrotic tissue and enzymes (yellow color)
Pus is a good indicator of active PD
The result i
s: a periodontal pocket
Pathologically deepened sulcus caused by bacterial infection
Coronal portion of the JE is invaded by bacterial plaque causing detachment from the tooth
The apical end of the JE migrates apically which can spread to cause resorption of the alveolar bone
Types of periodontal pockets
Suprabony : junctional epithelium has migrated below the CEJ but remains above the crest of the alveolar bone; associated with horizontal bone loss
Infrabony: junctional epithelium has migrated below the crest of the alveolar bone. Associated with vertical bone loss
Note: These periodontal pockets may be present in the absence of inflammation
Relating the importance of completing a periodontal assessment to quality of care
assists in developing an appropriate care plan that addresses a client's individualized needs
minimizes risk of missing a potential periodontal problem
identifies risk factors that the client may be able to modify to reduce risk of periodontal disease or stabilize current periodontal condition
educational material to motivate client to improve or maintain oral health
Risk Factors associated with susceptibility to periodontal disease
Modifiable vs Non modifiable
MODIFIABLE: those risk factors that can be changed
specific bacterial pathogens
poor oral self care
bleeding on probing
local contributing factors
NONMODIFIABLE: those risk factors that cannot be changed
history of periodontitis
gender and race
genetic disorders
genetic markers
please review these risk factors on pp 313-318 in Darby Walsh
AAP Guidelines
Originally developed by the American Academy of Periodontology in 1989 and updated in 1999
please see pp 327-328 in Darby/Walsh for the classification of gingival diseases and periodontitis. This table is also in your clinic manual in Section D
How do these guidelines support the periodontal diagnostic statement?
Darby M, Walsh M. Dental Hygiene Theory and Practice. 4th Ed. St. Louis, Missouri: Saunders; 2015.
The periodontal diagnostic statement is basically a summary of the clinical findings of the periodontal assessment. The AAP guidelines assist the dental hygienist in summarizing the data into a gingival or periodontal category.

It also guides the dental hygienist in making appropriate and individual clinical decisions regarding client care
Clinical attachment levels or clinical attachment loss- Which one is it?
These two terms are used interchangeably
clinical attachment level is: the level where the attachment is positioned in relation to the CEJ (must be positioned below the CEJ for attachment loss to occur)
clinical attachment loss is: the amount of attachment that is lost
both statements mean the same if the periodontal attachment has been altered/destroyed therefore the terms would be interchangeable
calculating CAL
When the gingival margin is at the same level as the CEJ (normal): the loss of attachment equals the pocket depth
ex. Probe depth= 3mm
gingival margin is at the CEJ= therefore CAL is 3mm
When the gingival margin is significantly coronal to the CEJ: the gingival margin level to the CEJ is
from the probing depth
ex. probe depth= 9mm
gingival margin to CEJ = -3mm (referred to as negative recession) therefore CAL is 6mm
When recession is present:
the probe depth to the distance between the gingival margin and the CEJ (amount of recession)
ex. probe depth= 4mm
CEJ to gingival margin=+2mm therefore CAL is 6mm
Approach to periodontal assessment
Just as a sequence is important when performing a dental assessment, it is just as important when completing the periodontal assessment.

During the dental assessment you would evaluate tooth by tooth but you will not be able to do that with the periodontal assessment because of the necessity to perform a number of measurements

Approach to periodontal assessment: PSR/full mouth probe first, then proceed to evaluate mobility, then recession, furcations, CAL, etc.
Furcations, mobility, mucogingival involvement and recession
pictures of periodontal findings
Each one of the items listed above indicates a regressive change in the periodontal condition
Furcations: this means that the clinical attachment levels and bone loss around the tooth have progressed to the furcation area of a multi rooted tooth. Because of the difficulty a client has in cleaning these areas once it has occurred, the client is at risk for further periodontal breakdown
Mobility: when the bone around a tooth is at normal levels, there is very little physiological movement. When movement occurs outside the normal levels, it can be a sign of periodontal trauma from occlusion or disease
Mucogingival involvement:Is the result of a pocket extending beyond the mucogingival junction and into the alveolar mucosa. This situation may then compromise the support of the tooth
Recession: Recession is a sign of attachment loss and occurs when the marginal gingiva migrates apically towards the CEJ and beyond. There are many causes including occlusal trauma, toothbrushing, abrasive tooth paste, etc.
for more information please refer to pp 334-338 in Darby Walsh
When the gingival margin is located on the anatomic crown, the level of attachment is determined by subtracting the depth of the pocket from the distance between the GM and the CEJ
Wilkins E. Clinical Practice of the Dental Hygienist. 12th Ed. Philadelphia: Wolter-Klower; 2017.
John's dental and periodontal findings are as follows:
Occlusal amalgam fillings on 3.6 and 4.6
hypoplasia on tooth 2.1 and a mesial rotation on tooth 1.4
probing depths are generalized 1-3 mm with a 4mm probe depth on the distal of the 4.6 and mesial of 4.7 buccal
tissue is generalized healthy with localized slightly enlarged papilla interproximal of 4.6 and 4.7
bleeding upon probing interproximal of 4.6 and 4.7

John brushes twice daily using fluoride toothpaste and flosses 3X/week. He has no other risk factors that could contribute to an increase in future caries
What is John's caries risk?
What do you think is contributing to the inflammation interproximal of tooth 4.6 and 4.7?
What would John's AAP statement be?
PSR review
Periodontal Screening and Recording (PSR)
A modified version of the World Health Organization's Community Periodontal Index of Treatment Needs
The guidelines for this index were established by the American Dental Association
This a method to screen clients for early signs of periodontal disease
Determines if a more thorough periodontal examination is required
Requires a WHO probe for the screening (designed especially for this index and the Community Periodontal Index of Treatment Needs
Clients at high risk will then need a comprehensive periodontal examination
Stedman's Medical Dictionary for the Dental Professional. 2nd Ed. Philadelphia: Wolter-Klower; 2012.
Camosun College Dental Hygiene Program Clinic manual. Current Edition.
See pages 129-130 in the clinic manual and page 319 in Darby/Walsh for information on how to use the PSR
Using and scoring PSR: mouth is divided into 6 sextants, and each tooth is probed as normal. Highest score is recorded for each sextant according to the codes (page 322 Darby and 129/130 in clinic manual)
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