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Periodontal Examination And Clinical Indices

Our main goal is to start treating patients of course , you are doctors and patients come with problems and we are there to help them and solve these problems. before we start treating the patient we want to know what we are going to do so its the cascade of medical paths in general including dentistry is that we aim to reach a Diagnosis example: we need to know that the patient has a skin disease to give him Amoxicillin , but If you dont know that he has a skin disease the patient will not has the right treatment So once we reach diagnosis we know that X disease is treated by Y procedure. The first thing we do in our clinics is examination includes the information that you need to know about the Patient that help you to reach the diagnosis.

Why do we do examination?
1- Basically to reach diagnosis 2- Precautions- we need to know more information about the patient because we dont want causing him/her other problems so we take some precautions. Ex: 1- Diabetic pt, needs some precautions : this pt is treated in the morning, the pt must take medication before coming to the clinic in the morning. 2- HIV , HBV extra important precautions, use disposable instruments, and if there are area to be used we cover it with two layers of isolator . 3-Special treatment needs. 4-Prognosis. 5-Motivation and education.

Main components and rationale

Its very important that we know many things about the patients, we need to look at history taking as something really important and not just a routine. Take history carefully sometimes the patients dont tell the truth, also dont think so much about what you need to ask or write ,the examination sheet has a checklist that you have to fill it: 1- date ,patient personal data, name, gender 2- chief complaint history of c/c . The reason that brought the pt to the health center is not necessarily the same reason that brought the patient to perio clinic, so when you write the chief complaint sometimes I see
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students writing : patient came for prosthetic treatment, placing bridges, or for extracting upper right first molar , we do not do bridges, fillings, extractions in perio clinic so it should not be a chief complaint that brought the patient to perio clinic, so this is the importance of why the patients first go to the ITU clinic for screening tests, so if the patient is referred from any other department the chief complaint will be written there. Remember this , if you dont know the chief complaint for your patient and you start doing the treatment that you see necessary at the end of the session the patient will say : I didnt come for this So look for the complaints of the patient , if you see other things, you need to give him a note, and tell him that he has problems although he dont know about them , maybe not painful or on the back teeth that he cant see them. so always look for the complaint of the patient, the reason why your patient enter the perio clinic specifically (the same is for cons and prostho clinics). 3-Medical history * Diseases complications: some diseases cause some other medical complications like: - Diabetes which cause : neuropathy, nephropathy ,retinopathy, CVD,stroke. - Hypertension which assosiated with real problems organ damages, renal problems, strokes if the patient is diabetic and hypertensive we need to pay attention. -Smokers have higher risk of strokes: we see alot of patients who are diabetic, hypertensive and they are smokers. The risk factors for strokes are: -stress -overweight Always look at patient file (if he has one) before every treatment and examination * Medications, in special conditions or diseases some patients dont have medication even diabetic patients sometimes they dont take medications they start with diet treatment, so not taking medication does not mean the patient is medically free. * Allergies *Smoking: smoker on not, duration of smoking, amount of smoking 4-dental history and oral hygiene practice. these things are very important to fill and to see before every appointment or treatment.

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Clinical Examination
In perio clinic we need to do : 1- Extra oral examination: normally is done in the ITU but sometimes the patient come to the ITU and get an extra oral examination and schedule an appointment for the next week , during this week or few days complications may appear or arise.(symmetry,lumps, ulcerations, lip competence , if there is anything attracts your attention, look at the patient carefully sometimes there is nothing there so we write N.A.D-No abnormality detected ) so before we enter the Intra oral examination we do extra oral examination. 2- Intra oral examination: examination of the tissues inside the mouth including: lips,cheek,tounge,floor of the mouth, soft and hard palate,mucosa, teeth . 3-periodontal examination: *clinical appearance of the gingiva *specific examination, measurements and index recording

By the way there is a whole chapter about periodontal diagnosis in your book , so you need to go through it quickly but you do not need to spend much time on it because it is covered somewhere else but if you have time it will help you in other courses.

What I need to say about this picture that there are no certainly accepted criteria to be used by everybody to reach a diagnosis or treatment plan, everybody can claim whatever they want so we need to define a criteria to say for example: this patient has gingival inflammation and we want to know the amount of inflammation do you think its a mild, moderate or severe inflammation? so thats the importance of having what we call: Periodonal indices.

sometimes researchers see thousands of patients to check for the presence or amount of the disease and this part of periodontal examination cascade which is called Epidemiology applies on other aspects as well but In perio it has clearly importance because it multifactorial and we look at different things at the same time: bone,gingiva, periodontal attachments, so thats why researchers invented what we call indices.
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-Clinicians focus on individual cases while epidemiologist focus on the population as a whole - Recall your knowledfe on epidemiology -epidemiology aims at: * determining amount & distribution of disease *investigation of cause 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 *location *bleeding, ulcerations, thickness *pus discharge *pocket formation *gingival recession *plaque accumulation *mobility *exposure of root furcations *and others ! too much informations, some of these parameters have more than one index ,

These are a form of a tool that have been suggested and accepted worldwide but what happen is because its used by so many researchers , they said that they will not take any classification or any index unless its accepted and discussed by really some authorized bodys. So we have the American academy of Periodontology, which is a leading organization nowadays they have many discussions to reach some agreement on indices.

Periodontal indices are useful :

*to help establishing diagnosis *to minimize disputes *to help following-up patients in a systematic and standardized manner *to facilitate communication between clinicians worldwide
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Whats indices we have? ?

we have many indices to assess the amount of gingival inflammation, for that some people think why I need all of these variations of indices like periodontal index or gingival index, and why we dont have one index to tell us about the status of the periodontal tissue!! these indices are: 1-Plaque index 2-Gingival index 3-Modified gingival index 4-Periodontal index 5-Mobility index 6-Furcation involvement 7-CPITN 8-Bleeding index 9-Papillary bleeding index according to the way of examination for any index, some indices need special instruments to be used like: perio-probe , Nabers probe, mouth mirror. and some indices need just looking at the tooth, visual examination and description like gingival recession. -> components of these indices are expressed in: 1- numbers: *probing depth measurements *CAL- clinical attachment level 2-Grades/classes: *furcation involvement *mobility 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. Now you need to listen carefully because we will explain the indices very fast as a revision for epidemiology course,so we dont need to spend too much time.

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Plaque Index ( Silness and Loe, 1964)

so as a general rule we record both soft and mineralize deposits at four sides or surfaces of the teeth are examined we record the amount of plaque(buccul,lingual,mesial,distal) scores: 0,1,2,3 -we take all surfaces scores and do scores average for each single examined tooth, then take all teeth scores averages and make average for the patient. normally we examined 6 assigned teeth which we call : Ramfjord teeth.

Example: If you examine your patient tooth and recorded the following readings for the plaque index: *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 for this tooth, then we repeat this calculations in all six assigned teeth and after that we do the average for all six teeth. so its: PI= plaque scores/ No. of surfaces examined

What is the signeficance/importance of this index? its important for oral hygiene practices basically when patients come to your clinic and you want to convince them to clean their teeth, when they go home and come back claiming that they did clean their teeth you will have index like a radiograph (standrdized index) to be able to tell the patient the difference between the first and the second visit, what change happened, if there is improvement or not. So its indication of hygiene practice and it helps you motivating and educating your patient as well.

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-less than 0.1 there is no inflammation -0.1-1.0 Mild inflammation -1.1-2.0 Moderate inflammation - 2.1-3 Heavy inflammation. Q : If the plaque index is more than three is it still severe or does it take a new class?? A : no it will not take a new class because the index score is 0,1,2,3 the average of this four scores will not be more than three . Other example: *Buccal : 3 *Palatal : 3 *Mesial :3 *Destal :3 PI for this tooth: (3+3+3+3)/4= 3 Heavy inflammation -Periodontal indices are ideally recorded for all the teeth in the mouth. - For practical reasons and to reduce the examination time, certain teeth we suggested by Ramfjord and this is widely accepted representative teeth: Ramfjord Index teeth are: (3,9,12,19,25,28)

(from the dr. slides)

Gingival Index ( Silness and Loe, 1963)

its to asses the amount of gingival inflammation and this is very important because we use it for diagnosis of gingivitis ,and to differentiate and classify the severity of the disease. - we examine 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 .

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IF we do examination and we found that there is a pinkish gingiva and there is no bleeding it has to be zero, if there are any clinical signs of inflammation, redness, slightly swelling of the gingival margin, so we have gingivitis. Now if we examine the patient and found a slight change in color, slight edema without bleeding its score 1 , if there is some redness and bleeding on probing its score will be 2 but if we found marked redness with spontaneous bleeding its 3 (summary: the table below) Calculations: GI= Total scores/No of surfaces examined Note- if we want to calculate the maximum score for gingival index use six teeth and 4 surfaces.

** when you write on the patient file diagnosis: is plaque induced gingivitis I will ask you about the extent and severity and you need to tell me three informations about the diagnosis: 1-what is the disease, the disease entity if its periodontitis or gingivitis and the type of them 2-whats the severity of the disease (mild , moderate ,severe). 3- the amount of teeth involved, for example: genarlized, moderate, localized, severe chronic periodontitis. please be careful because some students try to write generalized chronic severe periodontitis and thats wrong because chronic periodontitis is one type (disease entity)

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so it is Generalized severe chronic periodontitis.

Calculus Index
The calculus component of the periodontal disease index(PDI) by Ramfjord. We dont have to do calculus index in the clinic so the sheet is not included but there is an index that talk about the amount of calculus and its very easy I will leave it for you !!

Tooth Mobility Index (very important)

-Mobility beyond the physiologic range is abnormal -Mobility assesment (Miller Index): what if you have a tooth with a mobility that goes up to 0.3mm buccally and 1mm lingually what would you classify this case? First of all I want you to remmember when we used mobility index the classification is up to 1mm in both directions so the whole movement from buccul to lingual is just 1mm, if the sum is
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more than that you move to other level so its not 1mm buccaly and 1mm lingually-

Clinical Attachment Level (CAL)

this is the most important thing in the clinic because you base your diagnosis on this so I want you all to know how to make clinical attachement assesment, its very simple but if you did nt know the principles you will miss it. basically there is one rule, the normal healthy attachment of the periodontal tissue to the tooth is at the CEJ it is the location where the enamel which covers the anatomical crown of the tooth meet the cemental part of the root. - Ideally the attachment up to 3 mm above CEJ the attachment loss can occur when the gingiva at its original level, by the way attachment level doesnt mean all the time recession, sometimes the gingiva is there but its not attached, its separated by calculus. If the gingival margin above CEJ its not attachment loss. If the attachment moves apically its called attachment loss. Now all informations are from slides 26-36 - CAL its the distance between the base of the pocket and the CEJ. - Two measurments are recorded using a periodontal probe: * First measurment: Probing pocket depth(PPD) from the base of the pocket to the gingival margin. *Second mesurment is from ginginval margin to the CEJ.

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

JE: Junctional epithilum.

- If the gingival margin is coronal to the CEJ(i.e. CEJ is hidden), the attachment level is calculated by substracting the measurment from the gingival margin to CEJ from the Probing Pocket Depth(PPD).

GM: Gingival margin

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

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Probing depth measurment:

-Insert the probe -Direction: parallel to surface you examinig in a horizontal and lateral dimensions. -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.

Furcations by: Nabers probe

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Done by : Gewanna J. Ghazal. Nihad Bishara. Note- all slides are included, sorry if there are any mistakes.

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