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The complete periodontal examination
Fig. 1. Clinical appearance of healthy gingival tissues with female. (c) 40-year-old African-American female with nor-
no abnormalities in color, form, contour, or texture. mal gingival pigmentation. (d) 62-year-old Caucasian
(a) 14-year-old Caucasian female. (b) 36-year-old Caucasian female.
disease. This often can be determined in seconds by healthy site (e.g. such a site is often the adjacent
looking for signs of gingival inammation. The four attached gingiva) (Fig. 3).
most common signs of gingival inammation that Recognition of gingival swelling or edema requires
are routinely observed during a periodontal exami- that the clinician have a very clear mental picture of
nation are redness, swelling, bleeding on probing, the shape and texture of healthy gingiva (Fig. 1).
and purulent exudate (pus). Healthy gingiva is rm and resilient, whereas edema-
Gingival redness and swelling usually are seen tous tissue is often enlarged and puffy (Figs 2, 4 and
together and occur rst at the gingival margin. Without 5). If there is some uncertainty about the presence or
treatment the inammation can eventually involve absence of gingival edema, it is sometimes useful to
the entire interproximal area (Fig. 2a) and in some gently press the side of a periodontal probe against
cases extend into portions of the attached gingiva the tissue for a few seconds and then remove it. At
(Fig. 3). Sometimes the redness associated with gin- edematous sites the imprint of the periodontal probe
gival inammation can be quite subtle. If one is can often be seen (Fig. 5), whereas at sites without
uncertain about the presence of inammation-asso- marked edema no imprint will be observed. Recogni-
ciated gingival redness, it is useful to compare the tion of the presence or absence of gingival edema
color of the site in question with that of a conrmed helps the clinician determine if the tissues are
Fig. 2. Mandibular anterior region of a 55-year-old female attachment loss is somewhat less than 7 mm since the
with chronic periodontitis. (a) Note that the gingival gingival margin is coronal to the cementoenamel junction
papilla between the canine and lateral incisor is red and (not visible). The combination of gingival inammation
swollen. (b) Bleeding on gentle probing at the same site. plus a considerable amount of clinical attachment loss
Note: the 7 mm probing depth at the site. The clinical indicates that the site has periodontitis (2).
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Armitage
healthy or diseased. In addition, it also serves another absent (Fig. 2b). Inamed gingival tissues bleed
very important purpose anticipating the response when gently probed because of minute ulcerations
to treatment. Gingival edema and the accompanying in the pocket epithelium and the fragility of the
redness often disappears shortly after scaling and underlying vasculature. At the initial examination
root planing. Therefore, by noting that the tissues the percentage of sites that exhibit bleeding on prob-
are edematous during the examination, the clinician ing prior to treatment is a clinically useful piece of
can predict the likely response to therapy. information since it provides a full-mouth pretreat-
It should be remembered that not all areas of gin- ment assessment of the extent of gingival inamma-
gival redness and swelling are due to periodontal tion. For example, if 70% of the sites exhibit bleeding
diseases. Endodontic infections sometimes drain on probing prior to treatment, a decrease to 20% of
through the orice of a periodontal pocket thereby the sites after initial scaling and root planing and oral
mimicking a periodontal abscess (Fig. 6). Elsewhere hygiene instructions is encouraging to both the
this volume discusses in detail the diagnosis of endo- patient and periodontist by indicating that progress
dontic-periodontal lesions (10). has been made. In other words, knowledge of this
Bleeding on probing is a somewhat objective sign improvement reassures the patient and periodontist
of gingival inammation; it is either present or
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The complete periodontal examination
Fig. 7. Mandibular anterior region of a 55-year-old female overlying the central incisor can be seen. (b) Same area
with chronic periodontitis (same patient as shown in Fig. 2). after digital pressure has been applied to the gingiva of the
(a) Note the inamed area between the lateral and central central incisor. Note the purulent exudate at the distal
incisor. Color change including all of the attached gingiva gingival margin of the central incisor.
that their joint efforts to control the periodontal are associated with rapid and extensive destruction
infection are working. of bone and surrounding tissues. The diagnosis of
Although purulent exudate (pus) can occasionally acute periodontal lesions is discussed in detail else-
be found at sites with gingivitis, it is most often where in this volume (3).
detected at sites with chronic periodontitis. Pus is a
neutrophil-rich exudate that is found in about 35%
Detection of departures from normal
of sites with untreated periodontitis (1). Without ques-
anatomy, shape, and form
tion, its presence signies that the site is inamed
and infected. The best way to detect the presence of During the examination, notations should be made
pus is to gently apply digital pressure to the overlying of any deviations from normal periodontal anatomy
gingiva in a coronal direction (Fig. 7). Conventional such as alterations in contour, aberrant frenal attach-
wisdom suggests that the presence of pus is an unfa- ments, and minimal amounts or lack of keratinized
vorable sign. However, available data suggest that gingiva. These items are of particular importance if
suppuration is not a good stand-alone predictor of they interfere with the patient's ability to perform
the progression of chronic periodontitis (1). This state- oral hygiene procedures.
ment only applies to the relatively small amounts of Altered gingival contours can be the result of a
pus produced at sites with chronic periodontitis. The wide range of factors. They become clinically impor-
importance of copious amounts of pus often seen at tant if they create esthetic problems, make plaque
sites with periodontal abscesses is a different situa- control difcult, or interfere with function. For exam-
tion (Fig. 8). Highly purulent periodontal abscesses ple, gingival enlargement is a well-known side effect
Fig. 8. Highly purulent periodontal abscess on a mandib- from a large accumulation of pus. (b) A massive amount of
ular central incisor in a 38-year-old female. (a) The entire pus was released immediately after an incision was made
vestibule in the lower anterior region was markedly swollen to drain the abscess. (Courtesy of Dr. Gilbert V. Oliver.)
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Armitage
Fig. 9. A 35-year-old female with gingival enlargement Fig. 11. Bilateral large mandibular tori in a 45-year-old
associated with the ingestion of phenytoin to help control female that interfered with oral hygiene procedures.
cerebral seizures. The gingival enlargement created
esthetic problems for the patient and was her chief com-
plaint. of certain medications (e.g. phenytoin, nifedipine,
cyclosporine) (Fig. 9). Sometimes the enlargement
is due to unusual anatomic variations (Fig. 10). Occa-
sionally, mandibular tori can be come so large that
they interfere with chewing or impede access for
plaque control procedures (Fig. 11). Little needs to
be said about these alterations in contour because
they are clinically obvious and are often associated
with the patient's chief complaint. However, men-
tion should be made of subtle changes in gingival
contour that are sometimes overlooked, but have
clinical importance. In some patients with long-
standing chronic periodontitis, the gingiva becomes
rm and enlarged in reaction to the chronic inam-
mation (Fig. 1214). Sometimes such tissues are
referred to as ``brotic.'' In contrast to gingival enlar-
gement due to tissue edema, brotic enlargements
will not disappear after scaling and root planing. This
Fig. 10. Localized enlargement of the palatal gingiva in
knowledge is important since it helps the clinician
the molar region in a medically healthy 32-year-old
female. The enlargement was bilateral and was considered
anticipate what tissue changes will occur after non-
to be an unusual anatomic variation. The enlarged gingiva surgical therapy. The best way to conrm that the
was the focus of the patient's chief complaint. tissue is brotic is to gently press on the gingiva with
Fig. 12. A 49-year-old male with chronic periodontitis. (a) Lingual view of the same teeth shown in A. The
The altered contours and enlargement of the interproximal interproximal gingiva with increased redness was highly
gingival papillae were due to the longstanding inflamma- edematous, thereby increasing the likelihood of consider-
tion. The papillae were firm and ``fibrotic'' and the contours able shrinkage after nonsurgical therapy.
did not appreciably change after nonsurgical therapy. (b)
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The complete periodontal examination
Fig. 14. Gingiva with altered contours in the same patient Assessment of etiologic and predisposing
shown in Fig. 13 Some of the enlargement was due to factors
edematous changes and some had already become
fibrotic. In such cases, nonsurgical therapy will only During the course of a periodontal examination the
result in partial resolution of the gingival enlargement. clinician should begin to develop an idea of what
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Armitage
28
The complete periodontal examination
Fig. 19. Gingiva in a 38-year-old female that superficially of 8 mm (b). The patient had received scaling and root
looks healthy (a). Insertion of a periodontal probe on the planing by the referring dentist approximately 6 weeks
mesiobuccal side of the first molar reveals a probing depth prior to taking these photographs.
Probing depth is the distance from the gingival Some clinicians elect not to take clinical attachment
margin to the base of the probeable crevice. Probing loss measurements at the initial examination but wait
depth measurements are important because they until active treatment has been completed. The main
give a good approximation of the principal habitat reasons for this are that many changes occur in clin-
of periodontal pathogens (i.e. periodontal pockets). ical attachment loss as a result of therapy and the
Knowledge of the depth, extent, and location of measurements are easier to obtain once supragingi-
pockets gives the clinician a good idea where therapy val and subgingival calculus has been removed.
might be directed. Indeed, probing depth reduction Nevertheless, prior to placing patients in the main-
is often one of the important goals of many forms of tenance phase of therapy, clinical attachment loss
periodontal therapy. However, probing depth mea- readings should be taken since these measurements
surements do not necessarily give the best approx- serve as a baseline from which future determinations
imation of the amount of periodontal damage since of additional attachment loss are judged.
the reference point from which the measurements Gingival recession is the distance from the CEJ to
are taken (i.e. the gingival margin) may uctuate in the gingival margin (GM). Recession is often of major
apical or coronal directions. For example, at one concern to patients since it is a readily visible man-
examination the probing depth at a given site might ifestation of periodontal damage and can cause
be 4 mm, but at a later date gingival inammation esthetic problems when in occurs around anterior
can cause gingival swelling that results in migration teeth. Indeed, many patients have a chief complaint
of the gingival margin 2 mm coronally. The probing of ``receding gums.'' Therefore, at the initial exam-
depth at this later date would be 6 mm (i.e. 4 mm ination it is important to record the amount and
2 mm) even though no additional periodontal location of gingival recession.
damage had occurred. Conversely, if at a later date Damage from periodontal disease often involves the
2 mm of additional attachment loss occurred and the furcation areas of multirooted teeth. The severity of
gingival margin receded 2 mm apically, the probing furcation involvement is an important factor in deve-
depth would still be 4 mm. In other words, the gin- loping a treatment plan for affected sites. Therefore,
gival margin is not a xed landmark from which valid during a complete periodontal examination the loca-
assessments of additional damage can be made. tion and severity of furcation involvements should be
Clinical attachment loss is the distance from the recorded. One common classication system for furca-
cementoenamel junction (CEJ) to the base of the tion involvement includes: Class I (beginning), Class II
probeable crevice. If the CEJ landmark is missing (cul-de-sac), and Class III (through-and-through). A
because it has been destroyed by dental caries or has detailed discussion of the classication, diagnosis,
been removed by placement of a dental restoration, and importance of furcation involvements can be
another xed reference point can be used to measure found elsewhere in this volume (6).
attachment loss. Such landmarks might include the The nal assessment of periodontal damage that
apical margin of a restoration or the incisal edge of a should be recorded during a complete periodontal
tooth. When attachment loss measurements are taken examination is abnormal tooth mobility. Although
from a xed landmark other than the CEJ they are this symptom may have several causes other than
called relative attachment loss measurements. Clinical periodontal infections (5), loss of alveolar bone from
attachment loss or relative attachment loss measure- periodontitis is a major cause of abnormal tooth
ments are the best way to assess the presence or mobility. In addition, it is sometimes part of the
absence of additional periodontal damage. patient's chief complaint (e.g. ``My teeth are loose.'').
29
Armitage
The diagnosis and overall importance of tooth mobi- are collected virtually at the same time. In this step
lity are discussed in elsewhere in this volume (4). the examiner calls out a probing depth reading. Then
a second number is called out that represents the CEJ
to GM distance. Finally, if the site exhibits bleeding
Inspection of the teeth
on probing, the examiner says ``bleeding,'' and the
Although the primary focus of a periodontal exam- recorder places a ``dot'' ( ) in the box where the
ination is the periodontium, the teeth also need to be clinical attachment loss measurement will eventually
carefully inspected for dental caries, restorative pro- be inserted. As will be seen in a moment, the clinical
blems (6), and occlusal discrepancies (4). Tooth- attachment loss reading is a derived number obtained
related problems have considerable importance in by adding the CEJ to GM distance to the probing
the overall periodontal treatment plan. depth measurement.
For beginners the CEJ to GM reading can be a source
of confusion. There is usually no problem in under-
Recording the findings standing how to measure gingival recession (i.e. the
CEJ to GM distance when the gingival margin is apical
There are many types and styles of periodontal charts to the CEJ). The CEJ to GM measurement can be easily
to choose from. Selection of one charting system over obtained since both of the reference points (i.e. CEJ
another is entirely up to the preferences of the indi- and GM) are in full view. In addition, there is usually
vidual practitioner. Most acceptable charting sys- not a problem in understanding that the clinical
tems are simple, easy to ll out and read, and attachment loss can be obtained by adding the prob-
contain all of the relevant information collected dur- ing depth to the amount of gingival recession. For
ing the periodontal examination. An example of such example, if there is a 4 mm probing depth and 2 mm
a chart is shown in Fig. 20. The periodontal chart is a of gingival recession, the clinical attachment loss at
permanent record that can be used in assisting the the site is 6 mm (i.e. 4 mm 2 mm). The problem
practitioner to arrive at a diagnosis and prognosis, occurs when the gingival margin is coronal to the CEJ
develop a treatment plan, and longitudinally evalu- (i.e. when there is no gingival recession). In this case,
ate the response to therapy. only one of the reference points (i.e. GM) is in full
To efciently ll out a periodontal chart requires view of the examiner. To determine the CEJ to GM
the help of a dental assistant who serves as a recorder measurement the examiner must feel for the CEJ
of the examination ndings. As the clinician calls out with the tip of the periodontal probe and estimate
the measurements or assessments they are recorded how far coronally the GM is from the CEJ. If the GM is
in the chart. The chart shown in Fig. 20 has places for at the CEJ, the number called out by the examiner
assessments of probing depth, the presence or would be ``zero.'' If the GM is 1 mm coronal to the
absence of plaque, clinical attachment loss, the pre- CEJ, the number called out by the examiner would be
sence or absence of bleeding on probing, and the ``minus one.'' If the GM is 2 mm coronal to the CEJ,
distance from the CEJ to the gingival margin the number called out by the examiner would be
(CEJ GM). As mentioned above, in the section on ``minus two.'' In other words, when the GM is cor-
``Assessments of periodontal damage'' measure- onal to the GM, the CEJ to GM measurement is
ments or assessments at six sites around each tooth recorded as a negative number. For example, if there
are usually recorded. is a 4 mm probing depth and the CEJ to GM distance
Some examiners prefer to record, as the very rst is 2 mm, the calculated clinical attachment loss at
step, the presence or absence of plaque on each the site would be 2 mm (i.e. 4 mm 2 mm).
tooth and surface. In the chart shown in Fig. 20, if The chart in Fig. 20 has been lled out using the
supragingival plaque is present a ``dot'' ( ) is placed examination ndings from a patient with generalized
in the box where the probing depth measurements severe chronic periodontitis. In addition to the
will be inserted. The second step is to measure the probing depth, clinical attachment loss, and other
probing depth, CEJ to GM distance, and the presence assessments discussed above, commonly used
or absence of BOP. These three pieces of information symbols have been placed to reect the extent of
Fig. 20. Example of a periodontal chart showing some of the clinical information collected during examination of a 36-
year-old male with generalized chronic periodontitis. CAL clinical attachment loss; BOP bleeding on probing; PD
probing depth; Plaque visible plaque (plaque index score 2 using Silness & Lo e system (11)); CEJ GM distance
from cementoenamel junction to gingival margin.
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The complete periodontal examination
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The complete periodontal examination
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