examination and diagnosis

History of periodontal patients:

The assessment of the patient’s history requires an evaluation of the following six aspects:
1- Chief complaint:
It is essential to realize the patient’s needs and desires for treatment. The patient’s expectations have to be taken seriously and must be incorporated in the evaluation in harmony with the clinical situation.
2- Social and family history:
To get a feeling for his/her priorities in life, including the attitude to dental care.
A family history may be important, especially with respect to aggressive forms of periodontitis.
3- Dental history:
Information regarding signs and symptoms of periodontitis noted by the patient, such as:
migration and increasing mobility of teeth,
bleeding gums,
food impaction,
Difficulties in chewing have to be explored.
Chewing comfort
need for tooth replacement
4- Oral hygiene habits:
frequency and duration of daily tooth brushing,
interdental cleansing devices
chemical supportive agents, and regular use of fluorides
5- Smoking history:
Smoking has been documented to be the second most important risk factor after inadequate plaque control in the etiology and pathogenesis of periodontal diseases!!!
Detailed information about exposure time and quantity has to be gathered.
6-Medical history and medications:
(1) Cardiovascular and circulatory risks,
(2) Bleeding disorders,
(3) Infective risks,
(4) Allergic reactions.


Signs and symptoms of periodontal diseases:
A- Clinical:
color and texture alterations of the gingiva, e.g. redness and swelling
increased tendency to bleeding upon probing in the gingival sulcus/pocket area
May exhibit reduced resistance to probing perceived as increased probing depth and/or tissue recession.
Increased tooth mobility as well as drifting or flaring of teeth (in advance stages of periodontal diseases).
B- Radiographic: bone loss, either:
Horizontal: If bone loss has progressed at similar rates in the dentition, the crestal contour of the remaining bone in the radiograph is even and defined as being horizontal.
Angular bony defects are the result of bone loss that developed at different rates around teeth/tooth surfaces and, hence, that type is defined as being vertical or angular.
C- Histological:
An inflammatory cell infiltrate within a 1–2 mm wide zone of the gingival connective tissue adjacent to the biofilm on the tooth.
Pronounced loss of collagen
Marked loss of connective tissue attachment to the root and apical down growth of the dento-gingival epithelium along the root.

Results from clinical and animal research have demonstrated that chronic and aggressive forms of periodontal disease:
1. Affect individuals with various susceptibility at different rates (Löe et al. 1986)
2. Affect different parts of the dentition to a varying degree (Papapanou et al. 1988)
3. Are site specific in nature for a given area (Socranskyet al. 1984)
4. Are sometimes progressive in character and, if left untreated, may result in tooth loss (Löe et al.1986)
5. Can be arrested following proper therapy (Roslinget al. 2001)


So It is mandatory to examine all sites of all teeth for the presence or absence of periodontal lesions. (Single-rooted teeth should be examined at least at four sites (e.g. mesial, buccal, distal, and oral) and multi-rooted teeth at least at six sites (e.g. mesio-buccal, buccal, disto-buccal, distooral, oral, and mesio-oral) with special attention to the furcation areas.

Periodontal clinical parameters:

Bleeding on probing (BoP):
It is symptom which is indicative for disease progression.
It assess the vascular permeability changes associated with inflammation,
A periodontal probe is inserted to the bottom of the gingival/periodontal pocket applying light force and is moved gently along the tooth root surface. If bleeding is provoked by this instrumentation upon retrieval of the probe, the site examined is considered “bleeding on probing (BoP)-positive and, hence, inflamed.
A trauma to the tissues provoked by probing should be avoided, so a probing pressure of 0.25 N should be applied.
The mean of BoP score is given as a percentage.

The periodontal ligament and the root cementum:

to evaluate the amount of tissue lost in periodontitis
to identify the apical extension of the inflammatory lesion, the following parameters should be recorded:

Probing pocket depth (PPD):

probing depth, i.e. the distance from the gingival margin to the bottom of the gingival sulcus/pocket, is measured to the nearest millimeter by means of graduated periodontal probe with a standardized tip diameter of approximately 0.4–0.5 mm
Q Results from pocket depth measurements will only give proper information regarding the extent of loss of probing attachment in rare situations (when the gingival margin coincides with the cemento-enamel junction, CEJ).

Assessment of probing attachment level:

It is assessed to the nearest millimeter by means of a graduated probe and expressed as the distance in millimeters from the CEJ to the bottom of the probable gingival/periodontal pocket. The clinical assessment requires the measurement of the distance from the free gingival margin (FGM) to the CEJ for each tooth surface.
In cases with gingival recession, the distance FGM–CEJ turns negative and, hence, will be added to the PPD to determine PAL.


Errors inherent in periodontal probing:
A variety of factors influencing measurements made with periodontal probes include:
(1) The thickness of the probe used,
(2) Angulation and positioning of the probe due to anatomic features such as the contour of the tooth surface,
(3) The graduation scale of the periodontal probe,
(4) The pressure applied on the instrument during probing,
(5) The degree of inflammatory cell infiltration in the soft tissue and accompanying loss of collagen.
Therefore, a distinction should be made between the histologic and the clinical PPD to differentiate between the depth of the actual anatomic defect and the measurement recorded by the probe

The first three could be reduced or avoided by the selection of a standardized instrument and careful management of the examination procedure.

Q The terms probing pocket depth (PPD) and probing attachment level (PAL) have replaced the previously used terms pocket depth and gain and loss of attachment

A Because reductions in PPD following periodontal treatment and/or gain of PAL assessed by periodontal probing, do not necessarily indicate the formation of a new connective tissue attachment at the bottom of the previous lesion. Rather, such a change may merely represent a resolution of the inflammatory process and may thus occur without an accompanying histologic gain of attachment.

Assessment of furcation involvement:

It is assessed from all the entrances of possible periodontal lesions of multi-rooted teeth, i.e. buccal and/or lingual entrances of the mandibular molars. Maxillary molars and premolars are examined from the buccal, disto-palatal, and mesio-palatal entrances.
It is explored using a curved periodontal probe graduated at 3 mm (Nabers furcation probe)
Depending on the penetration depth, the FI is classified as “superficial” or “deep”:
Horizontal probing depth ≤3 mm from one or two entrances is classified as a degree I FI.
Horizontal probing depth >3 mm in at the most one furcation entrance and/or in combination with a degree I FI is classified as degree II FI.
Horizontal probing depth >3 mm in two or more furcation entrances usually represents a “through-and-through” destruction of the supporting tissues in the furcation and is classified as degree III FI.


Assessment of tooth mobility:
Increased tooth mobility may be classified according to Miller (1950):
Degree 0: “physiological” mobility measured at the crown level. The tooth is mobile within the alveolus to approximately 0.1–0.2 mm in a horizontal direction
Degree 1: increased mobility of the crown of the tooth to at the most 1 mm in a horizontal direction.
Degree 2: visually increased mobility of the crown of the tooth exceeding 1 mm in a horizontal direction.
Degree 3: severe mobility of the crown of the tooth both in horizontal and vertical directions impinging on the function of the tooth.
Increased tooth mobility could be seen after:
Overloading of teeth.
trauma from occlusion
Peri-apical lesions.
Periodontal surgery.

Diagnosis of periodontal lesions

Based on the information regarding the condition of the various periodontal structures (i.e. the gingiva, the periodontal ligament, and the alveolar bone) which has been obtained through the comprehensive examination presented above, Four different tooth-based diagnoses may be used:

• Gingivitis: This diagnosis is applied to teeth displaying:

Lesions confined to the gingival margin.
Bleeding on probing.
Sulcus depth of 1–3 mm irrespective of the level of clinical attachment.
Pseudo-pockets may be present
No attachment and alveolar bone loss
• Parodontitis superficialis (mild–moderate periodontitis):
Gingivitis
Attachment loss is termed “periodontitis”.
Not exceed 6 mm; a
Applied to teeth with “horizontal” loss of supporting tissues, representing suprabony lesions, and/or to teeth with “angular” or “vertical” loss of supporting tissues, representing infrabony lesions. “Infrabony” lesions include “intrabony one-, two- and three-wall defects” as well as “craters” between two adjacent teeth.
• Parodontitis profunda (advanced periodontitis):
PPD does exceed 6 mm;
Angular as well as horizontal alveolar bone losses are included in this diagnosis.
• Parodontitis interradicularis (periodontitis in the furcation area):
Attributed to multi-rooted teeth with FI
superficial FI if horizontal PPD ≤3 mm (parodontitis interradicularis superficialis)
Deep FI forhorizontal PPD >3 mm (parodontitis interradicularis profunda).


Oral hygiene status:
In conjunction with the examination of the periodontal tissues, the patient’s oral hygiene practices must also be evaluated.
Alterations with respect to the presence of plaque and gingival inflammation are illustrated in a simple way by the repeated use of the combined BoP) and plaque charts during the course of treatment.
Repeated plaque recordings alone are predominantly indicated during the initial phase of periodontal therapy (i.e. infection control) and are used for improving self-performed plaque control.
Repeated BoP charts alone, on the other hand, are predominantly recommended during maintenance care.