examination and charting

Question 1

Once your new patient has been seated, what do you do next?

Answer 1

Assure your pt. Small talk. Observe attitude/anxiety.Review medical and dental history. Explain what you plan to do.

Question 2

what do you do after you explain what you plan to do?

Answer 2

Next, gather information/data.
* Symptoms.
*Signs of disease.
*Extent of the disease.
*Signs of abnormalities [e.g.; prominent Tori].
*Local primary & aggravating factors.
*Behavioral and systemic aggravating factors.
*Limitations to treatment [local, Systemic].
(I will touch on the last two, next term)

Question 3

why do you examine?

Answer 3

To arrive at a DIAGNOSIS and a preliminary assessment of the PROGNOSIS upon which, a TREATMENT PLAN can be based.

Question 4

why do you chart?

Answer 4

• Base line data.
• Medico-legal reasons.
• Permanent record.

Question 5

what are the types of periodontal examinations?

Answer 5

Screening

Comprehensive

Emergency

Re-evaluation

Maintenance

Question 6

what do you do to not miss the less obvious signs/problems?

Answer 6

Always use a systematic approach so as to not miss the less obvious signs/problems

..And Use Repeated Circuits. Using these circuits will ensure that you do not miss out any local factor /clinical parameter that will aid in the diagnosis.

Question 7

what do you do in circuit 1/ overview of teeth/ predisposing factors?

Answer 7

NOTE and RECORD any…
Missing teeth.
Diastema.
Displaced/tipped/extruded/impacted.
Caries, defective restorations / Cast restorations.
Attrition, Abrasion, Abfraction, Erosion.
Poorly contoured restorations / Overhangs.
Food impaction sites.
Alignment of teeth.

Question 8

what is attrition? where is it seen?

Answer 8

ATTRITION: Tooth to tooth friction resulting in wearing of the surface.
Attrition may be seen on the incisal or occlusal surfaces.

Question 9

Wat is abrasion?

Answer 9

Abrasion refers to the wearing away of tooth structure from the friction of a foreign object.
(for example the foreign object may be a tooth brush)

Question 10

what is erosion/corrosion?

Answer 10

Erosion/corrosion – a chemical dissolution of the tooth - occurs across the whole tooth surface. ACIDS -> DIET (e.g. yoghurt, pickles, soft drinks), GASTRIC (e.g. from acid reflux) or even more occasionally from the environment (e.g. from chlorinated swimming pools).

its mainly due to acids.

Question 11

what is abfraction?

Answer 11

Abfraction: Wedge-shaped notching at cervical areas of involved teeth ofadults.

(for an interesting read, ck)
http://doctorspiller.com/Tooth_wear/attrition2.htm

‘While there are a number of studies linking occlusal forces to tooth flexure, few controlled studies exist that demonstrate the relationship between occlusal loading and abfraction lesions’

Question 12

what do you do for circuit 2/overview of gingiva?

Answer 12

VISUAL assessment of the gingiva
Thin/thick (bulky).
Inflamed/fibrous.
Sinus tract openings.
Surface lesions (e.g. ulcers/abcess – pursue)
Bone enlargements (exostosis).

TACTILE assessment.

• Swellings
• (if hard – exostosis/tori)
• [if soft –pursue]
• Is the gingiva tender to palpation? [if yes – pursue]

Question 13

what do you do for circuit 3/the sulcus/pocket/BOP/Furca/Loss of Attachment? when probing, what you need to pay attention to what three factors? What is the searching pressure?

Answer 13

By examining the sulcus, you identify the presence of a pocket and quantify it as well. Also you can demonstrate BOP (bleeding on probing) and assess loss of attachment (LA)(I will explain what this means in the lect.)

When probing, place probe into the sulcus, // to the long axis tooth. Gentle searching pressure [15-25 grams]. Use a stepping motion. Observe and record any BOP while probing.

THA ANGULATION
THE PRESSURE
THE DIAMETER OF THE PROBE (PROBE TIPS NEED TO HAVE A DIAMETER OF 0.6MM)

Question 14

what does CAL or Al stand for? what about LA? what does this precede?

Answer 14

LOSS of ATTACHEMENT [LA]This is also referred to as clinical attachment loss. [CAL] or AL (attachment loss)

LA= Distance from the CEJ to the base of the pocket. (There is LA in periodontitis but no LA in gingivitis)

Precedes bone loss.

Question 15

probing depth is measure from?

Answer 15

the gingival margin to the base of the pocket. the base of the pocket is where the junctional epithelium is.

Question 16

Where is the junctional epithelium usually? and therefore how is loss of attachment calculated?

Answer 16

at the CEJ.

loss of attachment = periodontal pocket depth - CEJ to the gingival margin.

but when the gingiva is normal you can’t see the CEJ so you need to use your probe to feel for the little gap that is the CEJ. when you measure the gingival margin to that groove you subtract the whole pocket depth minus the margin to CEJ and that will give you the loss of attachment at the bottom.

Question 17

What is loss of attachment (LA) considered to be the best indicator of? why?

Answer 17

LA is considered the best indicator of disease progression because it always measured from a FIXED point of reference – the CEJ

Probing depths may not always be close to LA measurements – the gingival margin tends to shift. E.g.; when there is edema due to inflammation or when there is recession. Hence PD is not the best indicator of disease progression.

Question 18

what precedes alveolar bone loss?

Answer 18

LA (CAL) precedes alveolar bone loss.

Question 19

There is no, LA (CAL) in gingivits why is this so?

Answer 19

when you have gingivitis the junctional epithelium is still at the CEJ.

Question 20

what is furcal involvement?

Answer 20

LOSS OF BONE IN THE FURCAL AREA (area of multirooted teeth)

Question 21

how is furcal involvement assessed?

Answer 21

ASSESSED USING A CURVED EXPLORER or NABOR’S probe

Question 22

how do you approach the loss of bone in the furcal area? what are the three types?

Answer 22

Approach a mesial or distal furca - from the palate.!

Type 1 (DIP) – less than 3 mm in depth
Type 2 (CAVE) -  at least 3 mm
Type 3 (TUNNEL) -  through and through

(don’t use the dip, cave, and tunnel on exam this is just to visualize these things)

Question 23

how many furcal defects can a 26 possibly have?

Answer 23

3 because there are three roots.

Question 24

what do you do for circuit 4/muco gingival problems?

Answer 24

Problems/abnormalities in the relationship of the MGJ (mucogingival junction) to the attached gingiva & the gingiva to the CEJ.
Gingival Recession.
Minimal Attached Gingiva - <2mm attachment [MAG].
Muco Gingival Involvement – 0 or (-) mm [MGI].
Frenum Pull.
(This may be confusing – I will try and explain this as well during my lecture)

Question 25

recession where is it measured from?

Answer 25

from CEJ to gingival margin

Question 26

what is MAG and what is MGI?

Answer 26

minimal attached gingiva, and muco gingival involvement

Question 27

how do you measure MAG (minimally attached gingiva)?

Answer 27

measure from the gingval margin to the mucogingival junction, then you subtract from that the pocket depth.

Question 28

how do you measure MGI (muco gingival involvement)?

Answer 28

you take the measurement from the gingival margin to the mucogingival junction, then you subtract it from the pocket depth which will be greater than or equal to the first measurement.

Question 29

how do you detect a frenum pull?

Answer 29

you pull the lip up and see if the margin moves or if there is blanching of the gingiva.

Question 30

what do you do for circuit 5/mobility (miller’s index) or what are the types?

Answer 30

Type 1 – < 1 mm (slightly mobile)
Type 2 – > 1 mm (Moderate)
Type 3 – >1 mm + some vertically movement.
(very mobile)

Question 31

what are circuits 6 and 7?

Answer 31

circuit 6
LOCAL AGGRAVATING (predisposing) FACTORS.  (talk about this in a couple of weeks)

(Behavioral and systemic aggravating factors: From observing, interviewing your patient and from medical record) [term 2]

circuit 7
Functional occlusal analysis.
You would have learnt about this in ‘occlusion’.

Question 32

what can our periodontal probe be used to record?

Answer 32

Probing depth
Bleeding on probing
Loss of attachment
Recession
MAG
MGI

Question 33

before making a diagnosis what three basic questions must you answer?

Answer 33

What type of periodontal disease or condition does my patient have?
What is the severity/ extent of the problem? (Is it mild/mod/severe?)
Is the disease localized or generalized?

You are then ready to make a diagnosis ofGINGIVITIS (chronic/acute) (local/gen) (extent) and/orPERIODONTITIS (local/gen) (extent).E.g.; Generalized moderate gingivitis with localized areas (indicate teeth) of mild periodontitis.

Question 34

what must you do before you make your diagnosis?

Answer 34

take a radiograph

Question 35

what is the typical patient with a chronic periodontitis ?

Answer 35

Over 30 years and have

The signs associated with chronic gingivitis and in addition….

Probing depths equal or greater than 6 mm.
Loss of attachment.
Recession. Furcal defects (when applicable)
Mobility.
And confirmed by radiographic evidence of bone loss.

Your diagnosis of periodontitis is therefore made after collectively considering the above signs.

Question 36

based on diagnosis (history + symptoms + clinical and radiologic signs) what’s next?

Answer 36

Based on your diagnosis (history + symptoms + clinical and radiologic signs) you should be able to determine the prognosis (more of this in term 2) and based on your prognosis, you can draw up a proposed treatment plan.

Question 37

what is taken to confirm your clinical findings and to assess the exten/type of bone loss only?

Answer 37

Radiographs are taken to confirm your clinical findings and to assess the extent/type of bone loss only.
Do not look at a radiograph only and make a periodontal diagnosis!