Examination of Periodontium

Examination of the periodontium

includes: 1 a visual examination of gingiva includes changes in color and shape 2.bleeding without apparent reason 2 probing of gingival sulci for pathologic deepening associated with periodontal disease 3 review of full mouth radiographs and posterior bitewing x-ray for lamina dura continuity and alveolar crest bone height

PERIODONTIUM
ALVEOLAR

BONE PERIODONTAL LIGAMENT CEMENTUM

GINGIVA

>is divided into free, attached and interdental papillae Structures: 1 Free gingiva unattached coronal portion of the marginal gingiva on the facial and lingual surfaces

GINGIVA

Interdental papilla located between proximal surfaces beneath contact points

COL saddle like depression joining 2 pyramid shaped papilla, 1 on facial and 1 on lingual

3 Free gingival groove demarcates the free gingiva from the adjacent attached gingiva

4 Attached gingiva consists of stippled tissue tightly bound down to the underlying bone and cementum of the tooth and extends from free gingival groove to the mucogingival junction which demarcates it from alveolar mucosa 5 Gingival sulcus potential space encircling the tooth sulcus depth varies from 0.5 3mm.

CLINICAL SIGNS OF A NORMAL GINGIVA

1 Color dependent on 1.1 vascularity of mucosa 1.2 hemoglobin in blood 1.3 attachment of CT 1.4 width of epithelium 1.5 degree of keratinization 1.6 pigmentation of epithelium 1.7 presence/absence of inflammation

2 Form and contour of interdental papillae (triangular), free gingiva margin and attached gingiva >related to morphology of tooth crown, spacing of teeth, contour of roots and presence of disease

STIPPLING
A protective adaptation to function Orange peel / skin appearance

3 Density or consistency depends on location, attachment and disease -normally firm, resilient,tightly bound to alveolar process except at free margin and interdental papilla borders on palpation : attached gingiva should feel primarily the contours of underlying bone and slight movement or resiliency of the interposed attached gingiva free gingiva should yield slightly more to pressure and give a faint sense of movement >surface palpation and light rubbing will reveal the degree of stippling and some extent the degree of keratinization

4 Depth of gingival sulcus may vary during active eruption, averages 0.5-3mm in adults, no bleeding on gentle probing 5 Attachment normal attachment should be on enamel or at CEJ, in elders should not be more than 1mm below CEJ

FINDINGS IN DISEASE

Principal clinical changes in periodontal diseases includes the following: 1 altered color- usually associated with chronic inflammation pale gingiva, buccal mucosa and skin associated with a more generalized disease seen in patients with ANEMIA >general redness of gingiva, buccal mucosa,palate and tongue indicates SENSITIVITY MANIFESTATION >when it includes general redness of face, hands, neck POLYCYTHEMIA

>melanosis

of the gingiva, buccal mucosa, palate indicates ADDISONS DISEASE >bluish cast to the gingiva, buccal mucosa, palate, tongue, hands and face may indicate CENTRAL OR PERIPHERAL CYANOSIS >alteration of color as a result of inflammation is related to CHRONICITY of the injurious agent and a response of tissue to irritation

>acute inflammation gives rise to a bright red erythematous discoloration >accretions, films, plaques and necrotic tissue may also alter the color >toothpastes and drugs >grayish slough easily removed suggests necrosis with pseudomembrane formation indicates ANUG

>granulation

tissue gives red discoloration and once it subside, forms a scar tissue, discolors to a white gingiva

>for dark races, melanosis of the other surface mucosa aside from the gingiva is noted >metallic pigmentation or amalgam tattoo is noted on the extraction site near a large amalgam restoration

2 Gingival bleeding even with gentle probing

3 Altered gingival form

4 Increased sulcular depth 5 Attachment apical to the CEJ

PERIODONTAL DISEASE
I. Gingivitis 1.1 Dental Plaque Induced 1.1.1 Modified by systemic factors Endocrine System - puberty associated - menstrual cycle-associated - pregnancy associated - diabetes mellitus 1.2.2 Blood Dyscrasias - leukemia and others

Modified by medications - drug influenced gingival diseases - drug influenced enlargements - oral contraceptive associated gingivitis Modified by Malnutrition 1.2 Non Plaque Induced Gingival diseases of specific bacterial, viral, fungal, genetic in origin, systemic conditions, traumatic lesions. Foreign body reaction

II. Chronic Periodontitis localized, generalized, slight, moderate and severe III. Aggressive localized and generalized IV. Periodontitis as manifestation of systemic disease Associated with hematological disorders, genetic disorders, necrotizing periodontal disease, abscess, endodontic lesion, developmental or acquired deformities

Note: classification is based on the rate of progression of the disease not the onset. ( see textbook Ongole page 513-515.

gingivitis modified by systemic factors 1) dilantin hyperplasia 2) pubertal gingivitis 3) pregnancy gingivitis

Associated with Endocrine puberty, menstrual cycle, pregnancy

leukemic gingivitis

chronic desquamative gingivitis

herpetic gingivostomatitis

Gingival atrophy and recession a. chronic atrophic senile gingivitis b. atrophic gingivitis

Periodontitis

Alteration of color

Alteration of form

Clinical feature/s

Symptom

Red or bluish Soft and Periodontal localized red spongy with pockets rolled thick Loss of bone margins and attachment

RADIOGRAPHIC SURVEY
1 Height and form of interdental alveolar bone crest 2 Lamina dura (continuity) 3 Status of interradicular areas

4 Overhanging margins 5 Width of periodontal ligament space 6 Periapical bone status, roots

PERIODONTAL CHART
should include the following: 1. record level of free gingival margin 2. depth of periodontal pockets 3. level of bone around the teeth 4. tooth mobility, malposition and loss dental caries, plaque and calculus index periodontium status

CHARTING
1 A record of level attachment and position of the free gingival margin relative to the CEJ is measured. Walk the probe around the teeth. 2 Measurement is made at six points mesial,center,distal of buccal or labial surfaces; mesial,center,distal of lingual surfaces

3 Free gingival margin drawn on the dental chart with 1mm graduations. 4 Use a calibrated probe marked at 3,6 and 8mm, probing the depth of each gingival sulcus to determine if it exceeds the acceptable 3mm depth.

Periodontal chart & probing

5 Mobility of all teeth should be tested in terms of numerical reference 1st distinguishable sign of movement , normal 2nd movement of 1mm from normal in any direction 3rd mobility in any direction more than 1mm rotation or depression

The End

OTHER DIAGNOSTIC METHODS

1 Gingival sulcular fluid flow & composition 2 Microbiologic test detects predominant bacteria in the lesion 3 Immunologic method immune response 4 Organulocytic migratory rate evaluate severity of gingivitis 5 Blood studies differential white cell count leukemia gingivitis & neutrophil dysfunctioncyclicneutropenia,agranulocytosis,
Chediak-Higashi disease