Gingival health--periodontal assessment. (Free Course).

An introduction to finding, locating, and assessing periodontal diseases

Objectives

1. Participant will be able to list at least three (3) data items which must be included in the initial data gathering appointment.

2. Participant will be able to list at least five (5) questions which must be asked of the patient during the initial data gathering appointment.

3. Participant will be able to demonstrate his/her ability to record in-depth information onto the patient record.

4. Participant will be able to list at least eight (8) types of clinical evidence to be observed on the patient's clinical radiographs.

5. Participant will be able to list at least two (2) "pitfalls" that might cause limitations on accurate readings when probing the sulcus.

6. Participant will be able to define the four (4) classes of mobility.

7. Participant will be able to define the four classes of furcation.

In today's busy dental practice, the dental team's role in data collection for diagnosis and treatment of periodontal disease is extremely important. Periodontal disease affects all patient groups regardless of age, race or socioeconomic status.

The dental profession has a legal responsibility to recognize and record findings and also to inform and educate the patient regarding this disease and the prognosis it presents. Periodontal disease, when recognized and treated early, can have predicable outcomes. The earlier the clinical symptoms are recognized, the opportunity for tooth loss is decreased.

A thorough periodontal examination should never be compromised due to time constraints. Adequate time must be provided for the collection of all the clinical data during diagnosis and treatment appointments.

Assessment of periodontal disease in the initial stages can be difficult. The disease itself is insidious and in the beginning stages the patient feels no discomfort. Most patients are truly unaware that they have a problem. Bleeding may be the only symptom that the patient notices and frequently that may be considered by the patient to be "normal".

On the patient's medical/dental history form (sample form on page 27), one of the best questions that can be an indicator of periodontal disease is ... "Do your gums bleed when you brush or floss?"

Utilizing an organized, consistent protocol for gathering periodontal clinical data is the key to efficiency and effectiveness in planning treatment for the patient.

The diagnostic data that is gathered at the initial appointment should include:

1. A completed, written medical history that is signed and dated by the patient and dentist.

2. Information about previous dental treatment including periodontal visits and maintenance instructions. (This may be acquired by an interview of the patient or utilizing a pre-printed list of questions.)

3. Radiographs, both past and present.

4. Clinical charting, both past and present.

Frequently, patients are referred to the dental office after relocation or when they decide to change dentists for various reasons. Most dental offices are very cooperative about sending records that are requested by the patients or new dentist. It is best to contact the dental office after the new patient calls for their first appointment thereby allowing time in the initial appointment to take new radiographs if the most recent films are not current.

Collecting and organizing clinical data can be a simple process once the significant steps are identified and followed with every patient in the same sequence every time the patient is seen. It is imperative to use an organized, systematic approach for each patient. Do not skip steps!

The patient interview is the first and most important step to gain the patient's confidence and trust and is the best source of data gathering available. Asking open-ended questions and listening carefully to the patient's answers provides information needed to assess a periodontal problem that may exist. Patients with moderate stage periodontal disease often complain of "bad breath." This is frequently noticed by someone other than the patient himself or herself and may be one of the primary reasons that they requested the appointment. Some patients notice bleeding when brushing and flossing and this may be another reason that they seek dental care.

The patient interview can provide valuable data when appropriate questions are asked. Examples of questions include:

1. When was your last visit to the dentist and what kind of treatment was provided at that time?

2. When was the last time you had your teeth cleaned?

3. What routine/technique do you follow when brushing and flossing?

4. Do you grind or clench your teeth? Has anyone told you that you grind your teeth in your sleep? Have you ever used a night guard?

5. How were previous teeth lost? (If there are missing teeth)

6. What brings you to the office today?

7. Are there any members of your family that have periodontal disease? (If yes, at what age was it diagnosed and what was the outcome?)

The medical history is used to evaluate the patient's potential to have systemic diseases that would contribute to the periodontal condition.

Thoroughness in patient interviewing during the medical history is important because patients frequently do not understand the relationship between their medical problems and medications and their overall dental health ... and often the reverse is also true. They may not understand that their oral health can affect their overall physical health.

Diseases such as hypertension, diabetes, heart disease, respiratory conditions, and AIDS, for example, can have a direct effect on the periodontium.

The complete history should include:

A. any background information about oral complaints that the patient may have

B. the updated medical history including any new medical conditions and medications

C. family and social history

Documents relating to the medical and dental history should be reviewed at each appointment. All notations should be written into the chart and signed and dated by the clinician and the patient.

The importance of medical and dental histories cannot be overemphasized. Not only do they provide information about the patient, but they also promote interaction that leads to trust and better patient compliance.

Radiographic Evaluation for Periodontal Disease

Intraoral radiographs aid in the detection of periodontal disease. A complete set of current radiographs is essential for making decisions concerning treatment planning and diagnosis. Although radiographic needs should be evaluated on a patient-by-patient basis, most adults require a complete full mouth series including four (4) posterior vertical bitewings. Panoramic surveys and horizontal bitewings do not provide an accurate diagnostic tool for evaluating the periodontal condition.

Radiographs provide clinical evidence and data that will determine the treatment for the patient and effect the outcomes of the disease. The data that can be observed on radiographs include:

1. Root length and morphology

2. Ration of the clinical crown length to the root length

3. Degree of bone destruction

4. Relationship of the maxillary sinus to the periodontally involved area

5. Furcation involvement

6. Calculus deposits

7. Root fractures

8. Root resorption 

9. Caries 

10. Supernumerary teeth

11. Impactions

The radiographs should also be reviewed to evaluate the type and degree of bone loss. This judgment is based on the amount of available bone in relationship to the root. The significance of the bone loss would vary depending on the length of the root.

Full-mouth radiographs should be taken every 3-5 years based on the patient's specific needs. Vertical bitewings should be taken yearly. Placing the bitewings in an orderly fashion in the mount allows comparison and contrast from one year's radiographs to the next. Digital imaging systems are especially useful with their capacity to store a chronological series of radiographs and display them for comparison.

Even though dental radiographs are the classic documents of the patient's history of dental disease, the films only tell you what has occurred, not when it occurred. Other limiting characteristics of radiographic use in diagnosis and prognosis of periodontal disease include:

* lack of buccal and lingual views of the alveolar bone

* the variation in appearance of periodontal ligament space

* two-dimensional distortion of overlapping anatomical structures

* inability to locate soft tissue margins

Radiographs also do not reveal minimal losses of bone. In fact, for bone loss to be diagnosed from a radiograph, 40% bone loss must have already occurred.

The use of high kVp produces a longer scale of contrast and is often preferred in detecting periodontal disease.

Periodontal Evaluation for Disease

When performing any part of the periodontal examination, it is very important to look for the early signs of disease activity. Bleeding on probing is one of the manifestations of the possibility of periodontal disease at its onset.

Disease activity is a frequently misused term. It is defined as a disease process resulting in attachment/bone loss. Active destruction of the periodontium is occurring. Bleeding on probing may be present with or without disease activity and the absence of bleeding upon probing does not necessarily indicate an inflammation-free site or a healthy oral environment. Pocket depth measurements are essential for providing the baseline assessments from which treatment plan, treatment progress, and continue care maintenance can be monitored.

Periodontal Probes

Various types of periodontal probes can be used to measure pocket depths. Most clinicians use their own personal preferences in determining which probe to use.

Most traditional probes are marked with 1-millimeter increments with the 4 and 6 mm marking absent. The probe reads 1, 3, 5, 7, 9, and 10 mm. Some probes have a black band indicating the 3, 5, 9, and 10-mm markings. Some clinicians prefer probes that are color coded because they are easier to read.

The Naber's probe or the Furcation probe is a blunt ended instrument that is used buccally and lingually on the periodontal structure to locate possible furcation involvement.

Since periodontal probing is such an important aspect of the periodontal examination, the technique must be systematic and consistent. The operator, when probing, will:

1. Use a lateral "walking" approach

2. Use only one brand of probe to achieve standardization

3. Dictate findings to the dental assistant who will chart data on a form that allows comparison of readings over time

4. Record six (6) regions around each tooth

Probing Technique: A Review

1. The probe is placed under the contact area between the line angles; making sure it is located at the interproximal area of the tooth.

2. The shank is rested between the teeth against the contact and the probe is angled under the contact area--always watching the angulation.

3. Round up to the next highest reading if the numbers on the probe are between one another.

4. Record the deepest reading in each segment.

5. Use all three measurements on the buccal and all three measurements on the lingual for accuracy.

6. Radiographs are utilized to allow double checking of reading.

7. Forcing the probe can create penetration of the periodontal tissues resulting in inaccuracies in the pocket depth and discomfort for the patient.

Even though periodontal probing is one of the best diagnostic tools we have available to assess periodontal disease, there are also certain "pitfalls" to be avoided:

* Subgingival calculus can interfere with accurate readings.

* In an area with elevated inflammation, the attachment is easily perforated.

* The pocket may be too tight to probe.

* The patient may be too sensitive to the probing.

Visibility is another factor that is extremely important to accuracy in probing. It is important that the probe be clearly visible to obtain accurate results. The skillful use by the dental assistant of the air/water syringe and the evacuation system will help keep the probing areas visible.

Bleeding at the gingival margin or sulcus is often the first indicator of gingivitis. Bleeding from the base of a pocket following the periodontal charting is an indicator of active periodontitis. These measurements are significant to two different types of periodontal disease and their future treatment.

Gingival Recession

Gingival recession is important to the periodontal examination because it accurately indicates the total amount of attachment loss. Attachment loss can vary from tooth to tooth. Any tooth can have attachment loss without having a pocket.

The amount of attached gingiva can be calculated by subtracting the probing depth from the width of the keratinized gingiva. Tissue color for keratinized tissue is lighter pink with a stippled appearance.

Mobillity

Mobility is an indicator of bone loss around the tooth. In order to accurately evaluate mobility, two non-working ends of the dental instruments (i.e., the mirror handle and the probe handle) are pressed on the buccal and lingual surfaces of the tooth. The amount of movement is measured and classified as:

Class O--Complete tooth stability

Class I--Tooth moves 1/2 mm buccally and 1/2 mm lingually.

Class II--All degrees between Class I and Class III mobility of up to 1 mm in any direction.

Class III--Tooth is terminally mobile. Greater than 1 mm in any direction and is depressible in the socket.

Furcations

Furcation involvement indicates a serious periodontal condition that if detected early is treatable with guided tissue regeneration.

Frequently, the areas that are most vulnerable to furcation involvement (the posterior areas of the mouth) are difficult to access. As a result, abscesses, progressive attachment loss and deep periodontal pockets may develop and be undetected.

The four classes of furcation involvement that are identified with the Naber's probe are:

Class I--the furcation can be probed to a depth of 3 mm. Using the probe, you can feel the anatomic fluting between the roots, but cannot engage the roof of the furcation.

Class II--the furcation can be probed to a depth greater than 3 mm, but not through and through. Everything between Class I and Class III.

Class III--The furcation can be completely probed through and through. The probe goes through one furcation and exits through another.

Class III+--Naber's probe can go halfway across the tooth.

Class IV--Clinically, the examiner can see through the furcation.

Furcation probing is significant because most teeth lost to periodontal disease are multi-rooted teeth, so it is absolutely essential to evaluate the furcation of these teeth. The classification of the involvement affects the choice of instruments that are used for debridement. The goal is to get the probe under the furcation, classify it and chart it.

The assessment and evaluation of the periodontal status of the patient involves the use of a thorough medical and dental history, radiographs, periodontal charting to include pocket depth, mobility and furcation involvement. From these clinical findings, the type of periodontal disease can then be defined and the appropriate treatment can be initiated. The earlier the detection and appropriate therapy is initiated, the less chance there will be for tooth loss.

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FREE COURSE

Please note: There is an administrative fee of $8 to cover a portion of grading and publication costs. This fee MUST accompany the test when it is submitted for grading. Use answer sheet opposite. APPROVED FOR TWO CONTINUING EDUCATION CREDITS--ADAA Members Only

TEST QUESTIONS

GINGIVAL HEALTH--PERIODONTAL ASSESSMENT

1. One of the best indicators of periodontal disease is:

A. sore gingiva

B. gums that bleed when brushed

C. 4mm (or more) pockets

D. a patient who has a history of not flossing

2. One of the common "complaints" from a patient with a more moderate stage of periodontal disease is:

A. sore teeth

B. uneven bite "one tooth too high"

C. bad breath

D. loose teeth

3. Medications, family/social history and medical conditions directly effect the health of a patient's periodontal health.

A. True

B. False

4. Periodontal probes are marked in the following increments:

A. 1, 2, 4, 6 mm

B. 1, 3, 5, 7, 9, 10 mm

C. 3, 5, 9, 10 mm

D. Both A and B

E. Both B and C

5. When measuring (probing) a pocket depth, one should round it out to the lower number when the numbers on the probe read between one another.

A. True

B. False

6. Which of the following are considered "pitfalls" of using a probe to assess periodontal disease?

A. Calculus interferes with probe readings

B. Tissue doesn't bleed and indicate inflammation

C. Too many varied types of probes

7. A Class II furcation:

A. can be completely probed from one furcation and then exits through the other

B. is easy to keep clean

C. when diagnosed, most likely means the tooth will be lost due to mobility

D. cannot be probed through and through

8. Keritinized tissue is both smooth and light pink.

A. True

B. False

9. One is more likely to develop furcation involvement in the posterior area of the mouth.

A. True

B. False

10.The ideal type of radiograph for diagnosing periodontal disease is/are:

A. Bitewings (vertical)

B. Bitewings (horizontal)

C. Panoramic

D. Full mouth films

E. Both A and D

F. Both B and C

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GLOSSARY

Furcation--region of division of the root portion of a tooth

Periodontal disease--site-specific infection of the dental supporting structures

Periodontal probe--hand instrument with millimeter calibrations used for measuring pocket depth, attachment width, and size of soft tissue lesions

Periodontitis--inflammation of the periodontium that extends beyond the gingiva

Periodontium--tissues that invest and support the teeth, i.e., the gingivae, cementum, periodontal ligament and alveolar and supporting bone

Pocket depth--distance in millimeters from the gingival margin to the base of the pocket

Prognosis--foretelling of the probable course of a disease or forecast of the outcome of a disease or regimen of treatment

Recession--loss of part or all of the gingiva over the root of a tooth 

Treatment plan--sequence of procedures planned for the treatment of a patient

This course is brought to you by the ADAA Council on Education and a grant from the John O. Butler Company