For the proper and accurate diagnosis of the periodontal condition in a patient, it is important to have a thorough periodontal examination. This examination should include the following:
- HEALTH AND DENTAL HISTORY Health and dental histories.
- Head, neck, and oral exam.
- Gingival exam and bleeding index.
- Deposit evaluation and plaque index.
- Evaluation of personal oral hygiene.
- Charting, complete with probing depths.
- and periodontal notations.
- Occlusal analysis.
- Screening using advanced diagnostic techniques.
A complete health history is necessary to identify any factors that will affect the patient’s treatment, as well as those factors that may predispose the patient to various periodontal problems. Patients with some systemic factors (e.g., medication or diseases) may exhibit certain gingival or periodontal problems. It should also be noted that periodontal surgery may be contraindicated for patients with certain conditions. Recently, smoking has been shown to be an important factor in the severity of periodontitis.
A dental history is necessary to address a patient’s chief dental complaint. A dental history also gives background irifonnation that may help with the diagnosis and treatment of that patient. Questions relating to bleeding gums, loose teeth, tooth migration (movement), foul taste, pain, sensitivity and his/her habits, may give helpful diagnostic information.
HEAD, NECK AND ORAL EXAMINATION
A complete head, neck, and oral exam should include an examination of all areas of the face and neck region. The tongue, insides of the cheeks, floor of the mouth, palate, and pharynx are observed and palpated. Saliva is checked for consistency, quality and quantity. The patient’s breath is also noted. This exam may reveal conditions that may indicate systemic or anatomical factors affecting periodontal health as well as other factors that may be signs of periodontal problems.
GINGIVAL EXAM AND BLEEDING INDEX
It is necessary to observe and palpate the gingiva because any changes in the size, shape, or consistency of the gingival tissue or any notation of bleeding or suppuration may indicate a periodontal problem. Palpation of the gingiva may help to locate infected tissues or a periodontal abscess, which is a localized area of swelling that contains purulent exudate.
During the gingival exam, the dentist should also note the presence of any recession, amount of attached gingiva, and position of the frena.
A bleeding index is taken by observing areas of the gingiva that bleed when a blunted instrument is gently inserted beneath the free gingival margin in the sulcular area. Because normal, healthy gingiva should not bleed, this index gives important diagnostic information.
Radiographs are needed to observe any bone loss or changes in the normal radiographic appearance of the periodontium.
Occlusal analysis is the observation of how the teeth on opposing arches occlude. As the opposing teeth occlude together, a great amount of force is exerted. As the periodontal tissues absorb most of this force, they adapt or change to accommodate to the force. When the tissues can not change to handle this force, some injury to the tissues begins to occur. Signs of occlusal trauma that can be observed during an occlusal examination include:
• Tooth mobility or migration.
• Sensitivity when biting down.
• Wearing away of the biting surfaces.
• Problems with the temporomandibular joint (TMJ).
Occlusal adjustments may be necessary to correct periodontal problems that originated from occlusal factors.
DEPOSIT EVALUATION AND PLAQUE INDEX
An assessment of the amount of hard and soft deposits present in the patient’s mouth is known as a deposit evaluation. The various categories of deposits on the tooth surface, include the following:
• Materia Alba
The mouth minor and an explorer instrument used for a deposit evaluation and plaque EVALUATION OF PERSONAL ORAL HYGIENE
An evaluation of a patient’s personal oral hygiene techniques may be a starting point in identifying the cause of periodontal condition of the patient It is important to establish a good rapport with the patient concerning his or her personal oral hygiene care because patient motivation and oral hygiene maintenance are critical to the success of any periodontal treatment plan. The best in- office periodontal treatment can fail due to the lack of appropriate personal oral hygiene care by the patient.
CHARTING AND CIRCUMFERENTIAL PROBING
Complete charting and circumferential probing are the keys to thorough periodontal assessment. To gauge the periodontal condition, the probe is gently inserted into the sulcus and circumferentially probed. Six readings are recorded for each tooth for periodontal condition, gingival recession and amount of plaque/deposits. Three readings are taken from the facial aspect of the tooth (distal, facial, and mesial), and three readings are recorded from the lingual aspect of the tooth (distal, lingual, mesial). The chart should also include a notation of any area that exhibits bleeding or suppuration upon probing.
Mobility is also recorded on the chart. Tooth mobility is evaluated by attempting to move the tooth between two blunt instruments. The degree of mobility is determined in the following manner N—No movement
1 degree— Movement in the facial and lingual direction up to 1 mm.
2 degrees— Movement greater than 1 mm in the facial and lingual directions.
3 degrees— Movement greater than 1 mm in the facial and lingual directions, and easy depression.
Furcation involvement means that periodontitis has progressed to the extent that the periodontium in the furcation area of a multirooted tooth has been destroyed. The extent of that destruction is measured by evaluating the furcation area.
There are four classifications of furcation involvements:
• Class I—The instrument can enter the furcation area horizontally 1—2 mm, but the arch of the furcation can not be detected.
• Class 11—The instrument can penetrate more than 2 mm or more than halfway into the furcation area but can not go through it
• Class Ill—The instrument can pass through the furcation to the opposite side. The furcation is occluded by gingival tissue and can not be seen clinically.
• Class P7—The furcation is visible as well as having an instrument pass through it.
ADVANCED DIAGNOSTIC TECHNIQUES
• Measure the effects of the inflammation process.
• Test for the presence of certain bacteria forms of periodontal disease, or for those whose in the patient’s mouth. condition has not improved after receiving standard periodontal treatment.
• Assess the patient’s immune response.