ICP L26: Assessment of periodontal disease

Question 1

Define periodontitis

Answer 1

An infection disease resulting in inflammation within the supporting tissues of the teeth, progressive attachment and bone loss - characterised by pocket formation and/or recession of the gingivae

Question 2

What is plaque induced gingivitis

Answer 2

Inflammation of the gingivae due to bacterial plaque (common) and has a slow onset which is usually painless

Question 3

Give examples of non-plaque induced periodontitis

Answer 3

1. Genetic/developmental disorders
2. Specific infections
3. Inflammatory and immune conditions
4. Reactive processes (epulides)
5. Neoplasms
6. Endocrine, nutritional and metabolic disorders
7. Traumatic lesions
8. Gingival pigmentation

Question 4

What are the issues with full mouth comprehensive periodontal assessments

Answer 4

1. Full assessment of plaque, calculus, bleeding and pocketing is time consuming and not always relevant
2. An index gives a quick rough measure of these and is a systematic way of reporting the findings
3. We can use screening methods to indicate who needs a more complete assessment (BPE)
4. Full assessments are needed as screening cannot be used for risk assessment/diagnosis

Question 5

What are periodontal pockets

Answer 5

Gingival sulcus is the space between the tooth and gingiva which is lined by sulcular epithelium - in periodontitis there is alveolar bone loss and the gums recede making them loose which causes pocket formation = deep and narrow spaces

Formation of pockets depends on probe dimensions, probing forces, inflammation of tissue and the periodontal probe penetrates at depth of the sulcus pocket

Question 6

What are pseudopockets

Answer 6

This is where probing depth is increased due to gingival swelling, overgrowth or anatomical features (semi-impacted, angulates or not fully erupted teeth) - there is no attachment loss

Question 7

What are true pockets

Answer 7

This is where probing depth is increased due to loss of periodontal attachment

Question 8

What is gingival recession

Answer 8

• Distance between CEJ and free gingiva
• Can be negative/positive due to pseudo pockets
• Added to PPD to calculate CAL/PAL
• In patients with periodontitis it is a measure of past disease
• Needed to diagnose risk and assess periodontal disease

Question 9

What is probing

Answer 9

The act of walking the tip of the probe along the JE within the sulcus or pocket to assess the health status of the periodontal tissue

The side of the probe should be kept in contact, and parallel with the root surface and then walked around the circumference

Question 10

What is BPE and outline the method

Answer 10

Basic periodontal examination - should be used for all routine dental examinations aged 7+

The dentition is divided into sextants (molar/premolar and canine/incisors) and examination is done with WHO probe which is gently inserted into gingival crevice and walked around - for each sextant, only the highest score is recorded (scores are given 0-4)

Question 11

Describe the WHO probe

Answer 11

• Ball end (0.5 mm)
• Dark black zone (3.5-5mm from tip of probe)
• Higher black lines at 8.5mm and 11.5mm

Question 12

What does an X in a BPE sextant represent

Answer 12

A sextant that is edentulous or has only one functioning tooth

Question 13

What does a * in BPE sextant represent

Answer 13

Signifies furcation involvement and is used as an adjunctive score

Question 14

What are the scoring codes for BPE

Answer 14

0 = No pockets >3.5 mm, no calculus/overhangs, no bleeding after probing (black band completely visible)

1 = No pockets >3.5 mm, no calculus/overhangs, but bleeding after probing (black band completely visible)

2 = No pockets >3.5 mm, but supra- or subgingival calculus/overhangs (black band completely visible)

3 = Probing depth 3.5-5.5 mm (black band partially visible, indicating pocket of 4-5 mm)

4 = Probing depth >5.5 mm (black band entirely within the pocket, indicating pocket of 6 mm or more)

• = Furcation involvement

Question 15

Outline treatment needs in relation to the scoring codes for BPE

Answer 15

0 = no treatment needed

1 = oral health intervention as bleeding on probing

2 = oral health intervention, scaling and elimination of plaque retentive restorative margins

3 = oral health intervention, scaling/root surface debridement, elimination of plaque retentive restorative margins

4 = OHI, RSD. Assess the need for more complex treatment; referral to a specialist may be indicated, and full mouth 6 point probing chart needed

• = OHI, RSD. Assess the need for more complex treatment; referral to a specialist may be indicated

Question 16

How is BPE in paediatric different compared to in adults

Answer 16

Only 6 teeth are used: UR6, UR1, UL6, LR6, LL1, LL6 (teeth that erupt first into the mouth)

This is done age 7-12 using only codes 0, 1, 2 in cooperative children

Question 17

What are the strengths and weaknesses of BPE

Answer 17

+
simple, rapid screening to identify those at risk
good indication of treatment appropriate to codes assigned

• not designed to monitor patients (need full charting)
  no distinction between true and false pockets
  lack detail within sextants
  no detail about recession
  no detail about furcation involvement
  often misused

Question 18

When is full periodontal probing (6 point pocket chart) done

Answer 18

When we need a full periodontal assessment (indicated by BPE as scores 3/4)

Question 19

What is done in full periodontal probing (6PPC)

Answer 19

6 measurements are given for each tooth using the same walking technique using a Williams or UNC15 probe

Bleeding on probing is noted, recession, furcation defects, mobility and full mouth plaque scores

Question 20

Describe the Williams probe

Answer 20

They have thin stainless steel tip (13mm) and a blunt tip end (1mm diameter) and there are gradations at 1, 2, 3, 5, 7, 8, 9, 10 mm (NOT 4 and 6)

Question 21

Describe the UNC15 probe

Answer 21

Most commonly used - thin stainless steel tip (15mm) with gradations at 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and black zones between 4-5mm, 9-10mm, 14-15mm

Question 22

Outline the technique for 6PPC

Answer 22

Probe along anatomy of the root surface and apply gentle pressure using a finger rest to give reproducibility and standardisation

Question 23

What can cause probing errors

Answer 23

1. Interference from the calculus on the tooth/root surface
2. Presence of overhanging restoration
3. Incorrect angulation of probe
4. Amount of pressure applied
5. Misread the probe
6. Shape, size of probe

Question 24

How does a radiographic examination of normal alveolar bone appear

Answer 24

The alveolar bone will have an external plate of cortical bone and an inner socket of thin compact cortical bone which is seen as the lamina dura on radiographs (bundle bone). There are cancellous trabecular between the external plates which act to support the alveolar bone

Question 25

How is bone loss determined on x-rays

Answer 25

Bone crest is usually 1-2mm apical to the CEJ and clinical crown:root ratios are determined according to the amount of root remaining in bone compared with the amount of tooth above bone level

Question 26

What is horizontal bone loss

Answer 26

When the level of bone is equal interdentally

Question 27

What is vertical/angular bone loss

Answer 27

Angular = when one tooth has lost more bone than that next to it

Vertical = when bone crest is more apical to CEJ adjacent to one tooth than to the other neighbouring tooth

Question 28

What radiographs are taken for periodontal examination

Answer 28

Horizontal bitewings (show crestal bone + indicated when pockets <5mm, show details of overhanging restorations)

Vertical bitewings (show bone levels in moderate-severe periodontitis around several teeth)

Periapicals (in severe periodontitis - show root morphology, furcation involvement, root share and periodontal-endodontic status)

Panoramic