Lecture 1 Flashcards
Clinical assessment
forms the basis for the patient’s care plan. We classify based off of what we see.
The periodontal assessment is a component of the clinical assessment and provides a
comprehensive picture of the patient’s periodontium health. During this process, you are just collecting facts to determine health or disease. This is also called baseline data. We need that baseline data for evaluation and comparison in future appointments. Whatever baseline data we have collected needs to be documented. These assessments need to be performed for all patients
The purpose of documentation is for
reference
history record
educational resource
medical and legal reasons.
Med Hx
Med hx has multiple purposes
-It ensures patient safety
-It aids the clinician by giving clues in evaluating a patients oral manifestations of systemic disease, and vis-versa can help clinician early detect systemic issues if patient is experiencing periodontal
problems.
-It can also help clinician know if they need to make precautions or modifications to patients treatment
-It helps build rapport and whatever they are experiencing can be answered in treatment plan.
- Questionnaire
- Interview
- Signed by clinician and patient for verification
- Documented We also want to record chief complaint.
Dental history
- Get chief complaint
A. Builds rapport and makes sure patient’s concerns are examined and addressed in treatment - Get info regarding dental history for diagnosis ( past and present dental treatment, OH practices, and habits, viewpoint towards dentistry)
A. Assess radio graphic needs
B. Assess immediate needs first
Extraoral assessment
Extra oral assessment
Purpose is to assess for any possible pathology
1.Visual inspect
2. Palpation
3. Auscultation (TMJ clicking and popping)
4.Olfaction
Intraoral assessment
Our focus is noticing deviations from normal in oral mucosa and record and notice deviations from normal in gingiva characteristics ( CCCTS (Color, consistency, contour (marginal and interdental papillae), texture, size (inflammation?) + localized or generalized)
Oral hyg assessment
Evaluate hard and soft deposits as well as stain
• Plaque biofilm
◦ Localized or generalized
◦ Plaque index score used as an educational tool
• Calculus
◦ Location: Sub or supra- gingival + surface or tooth number
◦ Extent: localized or generalized
◦ Quantity: light, mod, heavy
◦ Nature: tenacious, black, white, chalky, spicules, dark stained rings
• Stain
◦ Location: tooth surface or tooth number
◦ Extent: localized or generalized
◦ Color: see chart
◦ Intrinsic or extrinsic
◦ Quantity: light, mod, heavy
Types of stain
Dentition assessment
- Caries
A. G.V blacks classification - Restorations
A. Poor margins
B. Poor contours
C. Overhangs
D. Include implants and appliances - Proximal contact relationships
- Tooth abnormalities
A. Enamel pearls - Para functional habits
A. Bruxism
B. Grinding
C. Morsicatio buccarum/ labialis - Tooth wear ( can occur due to parafunctional occlusion or chemicals/diet or habits; conditions)
A. Attrition
a. Reduced salivary flow can increase friction
b. Parafunction
B. Erosion
C. Abfraction: flexion
D. Abrasion: caused by foreign object - Sensitivity or hypersensitivity
Periodontal exam: gingival characteristics
3’s and T
Color
Consistency
Contour
Texture
Periodontal exam: Probing Depths purpose
Probing Depths
1. Assess periodontal disease status
2. Support treatment planning decisions
3. Design individualized prevention plans
4. Evaluate success of treatment
5. Plan oral hygiene instruction
Cannot detect disease activity or predict destruction
Limitations
- JE penetration / puncture: Inflates (increases) clinical probing depth than actual tissue destruction
- Probing Force: Achieving apical extent of depth
- Placement and angulation variations
- Accuracy of depth: Influenced by inflammation, calculus, visibility and level of patient sensitivity
Periodontal exam: How to do PD
Measure from FGM to base of pocket
a. 6 sites per tooth
D. May have shallow pockets but have lots of recession ; could be associated with extensive bone loss
Perioexamination: clinical attachment level purpose
Provide the most accurate picture of periodontal status
Indicates destructive disease process has occurred
What does clinical attachment level estimate?
Periodontal support: level of attachment, JE and alveolar bone
Other then disease activity what other factors contribute to clinical attachment loss?
Previous therapy, aggressive toothbrushing, occlusal trauma, attrition-> extrusion
What is the clinical attachment level?
Distance in mm between CEJ and base of sulcus/pocket
What are the three levels for clinical attachment level?
Perio examination: clinical attachment calculation
if FGM is too coronal to CEJ then the FGM to CEJ measurement would be a negative number.
if FGM is apical to CEJ that would be a positive number
If FGM is right at the CEJ then that number would be 0. If FGM is in its correct place-slightly coronal to CEJ and PD is normal, subtract normal from normal— CAL should be 0. No movement of JE. In other words CAL=PD
Put PD on top and FGM to CEJ measurement on the bottom. Add or subtract based on FGM to CEJ number
If the FGM is overgrown coronal to CEJ, this is called a
Pseudo-pocket
In a pseudopocket, the loss of attachment is ____the pocket depth therefore the Probing depths ____ attachment level
Less than; overestimated
In a recession apical to CEJ, the loss of attachment is ____the pocket depth therefore the probing depth ___ CAL
Greater than; underestimated
If FGM is at CEJ, the loss of attachment is ____the pocket depth therefore the probing depth ___ CAL
Equal to; correctly estimated
Significance of CAL
Can probing depths alone indicate the amount of periodontal destruction?
No
Can patients with extensive attachment, loss and recession have healthy periodontium?
Yes, CAL isn’t more than 2-3 mm, no bleeding, shallow PD; successful tx; they may be in remission.
Perio assessment: bleeding on probing
- Bleeding on probing : primary sign of gingival inflammation
Amount indicative of level of inflammation (sparse to severe)
Does not correspond to amount of attachment level
Medications: anticoagulants and birth control pills
A. If occurring in perio maintenance patients this can indicate disease progression B. occurs in 30% of patients C. Absence means stability D. Smokers; heat causes vasoconstriction thereby reducing bleeding E. Do bleeding points during probing F. Detailed; include amount and rate
Perio assessment: suppuration
- Presence of suppuration or exudate
A. Feature of inflammation
B. Indicates ongoing infection
C. Amount not related to pocket depth
D. May not occur in all perio pockets
E. Detection:
a. During probing and applying digital pressure
F. If present needs to be recorded like BOP
Perio assessment: Level of free gingival margin (FGM)/ recession (RC/REC)
Free gingival margin measured in its relation to the CEJ
Perio assessment: Level of FGM normal and abnormal; how to calculate recession
A. Normal
a. Width: 0.5 mm to 2 mm
b. FGM slightly coronal to CEJ
B. Abnormal:
a. FGM is significantly coronal to CEJ (edema and hyperplasia)
b. FGM is apical to CEJ
1. Recession: apical migration of FGM from CEJ
A. measure from FGM to CEJ (mm)
B. Same locations as pocket depth measurements
Predisposing factors for recession
- Predisposing factors:
A. Anatomy:thickness of alveolar bone and gingiva
Etiology of recession
B. Possible could have happened because of perio pocket
a. Anatomy variations like high frenum attachment b. Occlusal trauma c. Smoking and chewing tobacco d. Inflammatory perio disease e. Trauma from brushing too hard f. Orthodontics g. Crown margins h. RPD clasps
Perio assessment: mobility
A. Can either be physiologic or pathologic
a. Physiologic
1. Normal function
2. Only up to PDL space not more
3. Range of mobility varies from time of day to what type of tooth
b. Pathologic
1. Excessive loss of support
2. Measure by using metal handles of two instruments; abnormal moves in buccal and lingual direction
A. Grade 0: physiologic only
B. Grade 1: slight pathology 1mm buccal lingual
C. Grade 2: moderate pathology 1-2 mm buccal lingual
D. Grade 3: severe pathology more than 2mm and with vertical displacement
3. Can be caused by:
A. inflammation
a. Pathologic mobility caused by inflammation can occur with or without bone loss
b. Inflammation typically occurs during severe gingivitis or early periodontitis, and periapical abscesses
B. Traumatic injury
C. Occlusal trauma
D. Diseases of the jaw
E. Pregnancy ( relaxation of tissues)
4. Rotation and elongation and extrusion?
5. Depends on:
A. Severity and distribution of bone loss ( severe mobility is not is not always due to amount of bone loss, and advanced periodontitis does not mean automatically will have mobility)
B. Length and shape of roots
C. Crown to root ratio
Perio assessment: furcation involvement about
A. Amount of bone loss interradicularly (horizontal or vertical)
B. Affected by:
a. Root trunk length
b. Concavities
C. Detection:
a. Presense
b. Location
c. Type
1. Bifurcated
A. Facial and lingual
B. Max 1st premolars: mesial and distal
2. Trifurcated
A. Facial
B. Mesial
C. Distal
d. Extent of involvement
A. Calibrated curved Nabors probe
Grades:
Grade 1: Flute of furca detectable; interradicular bone intact; recession is a clue and use xrays
Grade 2: Interradicular bone loss; varying pocket depths into furca; no communication with opposite side of tooth
Grade 3: Complete loss of interradicular bone; pocket formation; communication with opposite side of tooth; gingiva still covering cant see furcation clinically
Grade 4: Loss of attachment and gingival recession; furca clinical visible; can see right thru furca clinically, no gingiva
D. Difficult to maintain by clinician and patient E. Prognosis decreases with severity F. Depends on: a. Anatomy b. Location of furcation G. Requires radiographic and clinical examination H. Documentation: signals need for surgury follow non surgical therapy a. Recorded as pictured (direction of roots)
Perio exam: fremitus
A. Tooth vibrates under occlusal force
B. Only test maxillary teeth
a. Place finger over facial surfaces at the cervical third then ask patient to grind or tap
1. Degree of vibration: +=slight vibration, ++=vibration but no mobility +++=visible movement
Perioexam: mucogingival examination
A. Mucogingival involvement or defect: defect in relation between MGJ and FGM
a. Pathology and loss of attachment not required
b. Calculation for attached gingiva
1. Record width of keratinized gingiva (FGM to MGJ)
2. Subtract this from PD to get attached gingiva measurement
c. Mucogingival involvement occurs when no attached gingiva exists
B. Mucogingival conditions where mucogingival involvement can occur
a. Probing depth extends beyond MGJ
b. High frenum attachment
c. Inadequate attached gingiva
C. Mucogingival considerations
a. Delayed passive eruption
1. FGM fails to migrate apically like its supposed to when teeth erupt in children; instead remains at cervical third
