PERIODONTAL EXAMINATION AND CLINICAL INDICES

DENT 471 29/9/2013

Dr Hisham Al-Shorman

PERIODONTAL EXAMINATION
Why do we do examination?
Diagnosis Precautions Special treatment needs Prognosis Motivation and education

Main components and rationale

Date Patient personal data Chief complaint - history of c/c Medical history
Diseases - complications Medications Allergies Smoking Etc..

Dental history and oral hygiene practice

CLINICAL EXAMINATION
Extra-oral Intra-oral lips, cheeks, tongue, etc Periodontal
Clinical appearance of gingiva and teeth Specific examination, measurements and index recording

Is this gingiva inflamed?

gingivitis ? Periodontitis? If we disagree on something, how to reach an agreement?

Do we need specific criteria?

How about this?

And this?

If we can disagree on a single case, what about larges-scale studies where hundreds or thousands of persons are examined (i.e. epidemiological studies)
Clinicians focus on individual cases while epidemiologists focus on the population as a whole? Recall your knowledge on epidemiology

Epidemiology aims at:

Determining amount & distribution of disease Investigation of causes of disease Applying this knowledge for control of disease

Therefore, it plays a crucial role in dentistry and medicine in general

What factors we consider when examining periodontal patient?

Color Size And others! Location Bleeding Pus discharge Pocket formation Gingiva recession Plaque accumulation Calculus deposition Mobility Exposure of root furcations

Periodontal indices
These are a form of a tool that have been suggested and accepted worldwide. They are useful:
To help establishing diagnoses To minimize disputes To help following-up patients in a systematic

and standardized manner. To facilitate communication between clinicians worldwide Etc

What indices we have? Many!

Plaque index Gingival index Modified gingival index Periodontal index Periodontal disease index Mobility index Furcation involvement CPITN Bleeding index Papillary bleeding index Etc

Components of these indices are expressed in numbers:

Probing depth measurements CAL

OR in grades/ classes:
Furcation involvement Mobility

Some indices require the use of specific instrument Periodontal probe Nabers probe Mouth mirror Some requires only visual examination and description Gingival recession Dont worry, you will learn about the relevant indices as you progress in your study, But, for the present time, we will focus on the indices that you will use in the clinic as a routine screening measure

PLAQUE INDEX (Silness and Le, 1964)

Both soft debris and mineralized deposits are recorded Four surfaces of the teeth are examined : buccal, lingual, mesial and distal surfaces Scores: 0,1,2, 3

Scores are averaged for the tooth And then averaged for the patient

Score

Criteria

No plaque in the gingival area

A film of plaque adhering to the free gingival margin and adjacent area of the tooth, NOT SEEN BY NAKED EYE. The plaque may be recognized only by running the probe across the tooth surface Moderate accumulation of soft deposit s within the gingival pocket, or the tooth and gingival margin which can be SEEN BY THE NAKED EYE
ABUNDANCE of soft matter within the gingival pocket and/or on the tooth and gingival margin and adjacent tooth surface

Example:
if you examine your patient and recorded the following readings for the PI:

Buccal: 2 - moderate Lingual: 1 - mild Mesial: 2 - moderate Distal: 3 - heavy

Plaque Index for the tooth = (2+1+2+3)/4= 2 which indicates moderate plaque accumulation

Interpretation
Average Plaque Index
Interpretation

< 0.1

No plaque accumulation

0.1 1.0 1.1 2.0 2.1 3.0

Mild plaque accumulation Moderate plaque accumulation Heavy plaque accumulation

Periodontal indices are ideally recorded for all the teeth in the mouth. For practical reasons and to reduce the examination time, certain teeth were suggested by Ramfjord and this is widely accepted representative teeth:

Ramfjord index teeth: (3, 9, 12, 19, 25, 28)

6 4 1

4 6

GINGIVAL INDEX (Silness and Le, 1963)

Each of the four gingival areas of the tooth (facial, mesial, distal, and lingual) is assessed for inflammation and given a score from 0 to 3

Score

Inflammation

Bleeding

Appearance

None

No

Normal Slight change in color and mild edema with slight change in texture

Mild

No

Moderate

On probing

Redness, hypertrophy, edema and glazing

Marked redness, hypertrophy, edema and ulceration

Severe

Spontaneous

Interpretation
Average Gingival Index

Interpretation

< 0.1 0.1 1.0 1.1 2.0 2.1 3.0

No inflammation Mild inflammation Moderate inflammation Heavy inflammation

Examples

Moderate Inflammation Score 2

Mild inflammation Score 1

Sever inflammation Score 3

CALCULUS INDEX
The calculus component of the periodontal disease index (PDI) by Ramjford:
Score Criteria

0 1
2 3

Absence of calculus Supragingival calculus extending only slightly below free gingival margin (not more than 1 mm) Moderate amounts of supra-gingival and subgingival calculus or sub-gingival calculus alone Abundance of supra-gingival and sub-gingival calculus

TEETH MOBILITY
Mobility beyond the physiologic range is abnormal
Mobility assessment (Miller Index):
Degree Criteria

N
1

No movement noted clinically

Mobility in both buccal and lingual directions less than 1 mm Mobility in both buccal and lingual directions 1 mm or more Mobility more than 1 mm in a buccolingual direction as well as apico-occlusal direction

2
3

CLINICAL ATTACHMENT LEVEL (CAL)

It is the distance between the base of the pocket and the CEJ Two measurements are recorded using a periodontal probe. The first is the probing pocket depth (PPD) from the base of the pocket to the gingival margin The second measurement is from the gingival margin to the CEJ

If the gingival margin is apical to the CEJ, the two measurements are added together:

If the gingival margin is coronal to the CEJ (i.e. CEJ is hidden), the attachment level is calculated by subtracting the measurement from the gingival margin to CEJ form the probing pocket depth

If the gingival margin is at the CEJ level, the CAL is the same as the probing depth

Probing Depth Measurement

Probes Direction Force Illumination Drying

BLEEDING ON PROBING (BOP)

Important indicator of gingival health Even with no increased probing depth, BOP indicates inflammations Recorded after probing Six sites per tooth Designated by red dot

FURCATION

Nabers probe

Classification (Glickman,1953 )
Grade I Incipient, early stage Pocket is suprabony Mainly affects soft tissue No radiographic changes

Grade II Cul-de-sac More than a defect in the same tooth do NOT communicate +/- radiographic changes

Grade III Bone not attached to the dome of the defect Probe may/may not pass through the furcation Add buccal & lingual dimensions, if >buccolingual dimension of the tooth, it is grade III

Grade IV Interradicular bone destroyed Soft tissue recession furcation clinically visible A tunnel between the roots Probe passes trough the defect