Examination of PeriodontiumExamination of Periodontium

Examination of the periodontiumExamination of the periodontium

includesincludes::

1 a visual examination of gingiva includes changes 1 a visual examination of gingiva includes changes in color and shapein color and shape

2.bleeding without apparent reason2.bleeding without apparent reason

2 probing of gingival sulci for pathologic 2 probing of gingival sulci for pathologic deepening associated with periodontal diseasedeepening associated with periodontal disease

3 review of full mouth radiographs and posterior 3 review of full mouth radiographs and posterior bitewing x-ray for lamina dura continuity and bitewing x-ray for lamina dura continuity and alveolar crest bone heightalveolar crest bone height

PERIODONTIUMPERIODONTIUM

GINGIVAGINGIVAALVEOLAR BONEALVEOLAR BONE

PERIODONTAL PERIODONTAL LIGAMENTLIGAMENT

CEMENTUMCEMENTUM

GINGIVAGINGIVA>is divided into free, attached and interdental papillae>is divided into free, attached and interdental papillae

Structures:Structures:

1 1 Free gingivaFree gingiva

unattached coronal unattached coronal

portion of theportion of the

marginal gingiva on marginal gingiva on

the facial and lingual the facial and lingual

surfacessurfaces

2 2 Interdental papillaInterdental papilla located between located between proximal surfaces proximal surfaces beneath contact beneath contact points points

COLCOL – saddle – saddle like depression like depression joining 2 pyramid joining 2 pyramid shaped papilla, shaped papilla,

1 on facial and 1 on 1 on facial and 1 on linguallingual

3 3 Free gingival grooveFree gingival groove – – demarcates the free demarcates the free

gingiva from the gingiva from the adjacent attached adjacent attached gingivagingiva

4 Attached gingivaAttached gingiva – consists of stippled tissue tightly bound down to the underlying bone and cementum of the tooth and extends from free gingival groove to the mucogingival junction which demarcates it from alveolar mucosa

5 Gingival sulcusGingival sulcus – potential space encircling the toothsulcus depth varies from 0.5 – 3mm.0.5 – 3mm.

CLINICAL SIGNS OF A NORMAL CLINICAL SIGNS OF A NORMAL GINGIVAGINGIVA

1 1 ColorColor – dependent on – dependent on

1.1 vascularity of mucosa1.1 vascularity of mucosa

1.2 hemoglobin in blood1.2 hemoglobin in blood

1.3 attachment of CT1.3 attachment of CT

1.4 width of epithelium1.4 width of epithelium

1.5 degree of keratinization1.5 degree of keratinization

1.6 pigmentation of 1.6 pigmentation of epitheliumepithelium

1.7 presence/absence of 1.7 presence/absence of inflammationinflammation

2 2 Form and contourForm and contour of of interdental papillae interdental papillae (triangular), free (triangular), free gingiva margin and gingiva margin and attached gingivaattached gingiva

>related to >related to morphology of tooth morphology of tooth crown, spacing of crown, spacing of teeth, contour of roots teeth, contour of roots and presence of and presence of diseasedisease

STIPPLINGSTIPPLING

A protective adaptation to A protective adaptation to functionfunction

Orange peel / skin Orange peel / skin appearanceappearance

3 3 Density or consistencyDensity or consistency – depends on location, – depends on location, attachment and diseaseattachment and disease-normally firm, resilient,tightly bound to alveolar -normally firm, resilient,tightly bound to alveolar process except at free margin and interdental process except at free margin and interdental papilla borderspapilla borders

on palpation :on palpation :attached gingiva attached gingiva should feel primarily the contours should feel primarily the contours

of underlying bone and slight movement or of underlying bone and slight movement or resiliency of the interposed attached gingivaresiliency of the interposed attached gingiva

free gingiva free gingiva should yield slightly more to pressure should yield slightly more to pressure and give a faint sense of movementand give a faint sense of movement

>surface palpation and light rubbing will reveal >surface palpation and light rubbing will reveal the degree of the degree of stipplingstippling and some extent the and some extent the degree of degree of keratinizationkeratinization

4 4 Depth of gingival Depth of gingival sulcussulcus – may vary – may vary during active eruption, during active eruption, averages averages

0.5-3mm0.5-3mm in adults, no in adults, no bleeding on gentle bleeding on gentle probingprobing

5 5 AttachmentAttachment – normal – normal attachment should be attachment should be on enamel or at CEJ, in on enamel or at CEJ, in elders should not be elders should not be more than 1mm below more than 1mm below CEJ CEJ

FINDINGS IN DISEASEFINDINGS IN DISEASE

Principal clinical changes in Principal clinical changes in periodontal diseases includes the periodontal diseases includes the

following:following:

1 1 altered color-altered color- usually associated usually associated with chronic inflammationwith chronic inflammation

pale gingiva, buccal mucosa and skin pale gingiva, buccal mucosa and skin associated with a more generalized associated with a more generalized disease seen in patients with disease seen in patients with ANEMIAANEMIA

>general redness of gingiva, buccal >general redness of gingiva, buccal mucosa,palate and tongue indicates mucosa,palate and tongue indicates SENSITIVITY MANIFESTATIONSENSITIVITY MANIFESTATION

>when it includes general redness of >when it includes general redness of face, hands, neck face, hands, neck POLYCYTHEMIAPOLYCYTHEMIA

>>melanosis of the gingiva, buccal melanosis of the gingiva, buccal mucosa, palate indicates mucosa, palate indicates ADDISON’S DISEASEADDISON’S DISEASE

>bluish cast to the gingiva, buccal >bluish cast to the gingiva, buccal mucosa, palate, tongue, hands mucosa, palate, tongue, hands and face may indicate and face may indicate CENTRAL CENTRAL OR PERIPHERAL CYANOSISOR PERIPHERAL CYANOSIS

>alteration of color as a result of >alteration of color as a result of inflammation is related to inflammation is related to CHRONICITYCHRONICITY of the injurious of the injurious agent and a response of tissue agent and a response of tissue to irritationto irritation

>acute inflammation gives rise to a bright >acute inflammation gives rise to a bright red erythematousred erythematous discoloration discoloration

>accretions, films, plaques and necrotic >accretions, films, plaques and necrotic tissue may also alter the colortissue may also alter the color

>toothpastes and drugs>toothpastes and drugs

>grayish slough easily removed suggests >grayish slough easily removed suggests necrosis with pseudomembrane necrosis with pseudomembrane formation indicates formation indicates ANUGANUG

>>granulation tissue gives granulation tissue gives redred

discoloration and once it discoloration and once it subside, forms a scar tissue, subside, forms a scar tissue, discolors to a white gingivadiscolors to a white gingiva

>for dark races, >for dark races, melanosismelanosis of of the other surface mucosa the other surface mucosa aside from the gingiva is aside from the gingiva is notednoted

>metallic pigmentation or >metallic pigmentation or amalgam tattooamalgam tattoo is noted on is noted on the extraction site near a the extraction site near a large amalgam restorationlarge amalgam restoration

2 2 Gingival Gingival bleedingbleeding even even with gentle with gentle probingprobing

3 3 Altered Altered gingival formgingival form

4 4 Increased sulcular depthIncreased sulcular depth

5 5 Attachment apical to the CEJAttachment apical to the CEJ

PERIODONTAL DISEASEPERIODONTAL DISEASE

I. GingivitisI. Gingivitis 1.1 Dental Plaque Induced1.1 Dental Plaque Induced

1.1.1 Modified by systemic factors1.1.1 Modified by systemic factors Endocrine SystemEndocrine System

- puberty associated- puberty associated - menstrual cycle-associated - menstrual cycle-associated - pregnancy associated- pregnancy associated - diabetes mellitus- diabetes mellitus 1.2.2 Blood Dyscrasias1.2.2 Blood Dyscrasias - leukemia and others- leukemia and others

Modified by medicationsModified by medications

- drug influenced gingival diseases- drug influenced gingival diseases

- drug influenced enlargements- drug influenced enlargements

- oral contraceptive –associated gingivitis- oral contraceptive –associated gingivitis

Modified by MalnutritionModified by Malnutrition

1.2 Non Plaque Induced1.2 Non Plaque Induced

Gingival diseases of specific bacterial, viral, Gingival diseases of specific bacterial, viral, fungal, genetic in origin, systemic conditions, traumatic fungal, genetic in origin, systemic conditions, traumatic lesions. Foreign body reactionlesions. Foreign body reaction

II. Chronic PeriodontitisII. Chronic Periodontitis localized, generalized, slight, moderate and severelocalized, generalized, slight, moderate and severe

III. AggressiveIII. Aggressive localized and generalizedlocalized and generalized

IV. Periodontitis as manifestation of systemic diseaseIV. Periodontitis as manifestation of systemic disease Associated with hematological disorders, genetic Associated with hematological disorders, genetic

disorders, necrotizing periodontal disease, abscess, disorders, necrotizing periodontal disease, abscess, endodontic lesion, developmental or acquired endodontic lesion, developmental or acquired deformitiesdeformities

Note: classification is based on the rate of progression of Note: classification is based on the rate of progression of the disease not the onset. ( see textbook Ongole page the disease not the onset. ( see textbook Ongole page 513-515.513-515.

gingivitis modified by gingivitis modified by systemic factorssystemic factors

1) dilantin hyperplasia1) dilantin hyperplasia

2) pubertal gingivitis2) pubertal gingivitis

3) pregnancy gingivitis3) pregnancy gingivitis

Associated with Endocrine – puberty, menstrual cycle, Associated with Endocrine – puberty, menstrual cycle, pregnancypregnancy

leukemic gingivitis

chronic chronic desquamativdesquamative e

gingivitisgingivitis

herpetic gingivostomatitisherpetic gingivostomatitis

Gingival Gingival atrophy and atrophy and recessionrecession

a. chronic a. chronic atrophic senile atrophic senile gingivitisgingivitis

b. atrophic b. atrophic gingivitisgingivitis

PeriodontitisPeriodontitis

Alteration of Alteration of colorcolor

Alteration of Alteration of formform

Clinical Clinical feature/sfeature/s

SymptomSymptom

Red or bluish Red or bluish redred

Soft and Soft and spongy with spongy with rolled thick rolled thick

marginsmargins

PeriodontalPeriodontal

pocketspockets

Loss of Loss of bone and bone and

attachmentattachment

localizedlocalized

RADIOGRAPHIC SURVEYRADIOGRAPHIC SURVEY

1 Height and form of 1 Height and form of interdental alveolar bone interdental alveolar bone crestcrest

2 Lamina dura (continuity)2 Lamina dura (continuity)

3 Status of interradicular areas3 Status of interradicular areas

4 Overhanging margins4 Overhanging margins

5 Width of periodontal 5 Width of periodontal ligament spaceligament space

6 Periapical bone status, 6 Periapical bone status,

rootsroots

PERIODONTAL CHARTPERIODONTAL CHART

should include the following:should include the following:

1. 1. record level of free gingival marginrecord level of free gingival margin

2. depth of periodontal pockets2. depth of periodontal pockets

3. level of bone around the teeth3. level of bone around the teeth

4. tooth mobility, malposition and loss4. tooth mobility, malposition and loss

dental caries, plaque and calculus indexdental caries, plaque and calculus index

periodontium statusperiodontium status

CHARTINGCHARTING

1 A record of level attachment and 1 A record of level attachment and position of the free gingival margin position of the free gingival margin relative to the CEJ is measured. relative to the CEJ is measured. WalkWalk the probe around the teeth. the probe around the teeth.

2 Measurement is made at 2 Measurement is made at sixsix points pointsmesial,center,distal of buccal or mesial,center,distal of buccal or labial surfaces; mesial,center,distal labial surfaces; mesial,center,distal of lingual surfacesof lingual surfaces

3 Free gingival margin drawn on 3 Free gingival margin drawn on the dental chart with 1mm the dental chart with 1mm graduations.graduations.

4 Use a calibrated probe marked 4 Use a calibrated probe marked at 3,6 and 8mm, probing the at 3,6 and 8mm, probing the depth of each gingival sulcus to depth of each gingival sulcus to determine if it exceeds the determine if it exceeds the acceptable 3mm depth.acceptable 3mm depth.

Periodontal chart & probingPeriodontal chart & probing

5 Mobility of all teeth should be tested in 5 Mobility of all teeth should be tested in terms of numerical referenceterms of numerical reference11stst – distinguishable sign of movement , – distinguishable sign of movement , normalnormal22ndnd – movement of 1mm from normal in – movement of 1mm from normal in any directionany direction33rdrd – mobility in any direction more than – mobility in any direction more than 1mm1mm

rotation or depressionrotation or depression

The The EndEnd

OTHER DIAGNOSTIC METHODSOTHER DIAGNOSTIC METHODS

1 1 Gingival sulcular fluidGingival sulcular fluid – flow & composition – flow & composition

2 2 Microbiologic testMicrobiologic test – detects predominant – detects predominant bacteria in the lesionbacteria in the lesion

3 3 Immunologic methodImmunologic method – immune response – immune response

4 4 Organulocytic migratory rateOrganulocytic migratory rate – evaluate – evaluate severity of gingivitisseverity of gingivitis

5 5 Blood studiesBlood studies – differential white cell count – differential white cell count leukemia gingivitisleukemia gingivitis & neutrophil & neutrophil dysfunctiondysfunctioncyclicneutropenia,agranulocytosis,cyclicneutropenia,agranulocytosis,

Chediak-Higashi diseaseChediak-Higashi disease