Sara Pavlović

Marko Pongrac
• diagnosis of periodontal disease
• estimation of severity
• determination of prognosis
• evaluation of treatment outcome

„They are an addition to the clinical

examination, NOT a substitute for it!“
 Outlined by a thin, radiopaque line adjacent to the
periodontal ligament (PDL) and at the alveolar crest,
referred as lamina dura.

Width and shape of interdental bone and angle of the

crest vary according to the convexity of the proximal
tooth surfaces and the level of the cementoenamel
junction.

The faciolingual diameter of the bone is related to the

width of the proximal root surface.
Periapical and bite-wing projections offer the most diagnostic information and are most
commonly used in the evaluation of periodontal disease

Richard established the following four criteria to determine

adequate angulation of periapical radiographs:

1. Radiograph should show the tips of molar cusps with little or none of the occlusal
surface showing.

2. Enamel caps and pulp chambers should be distinct.

3. Interproximal spaces should be open.

4. Proximal contacts should not overlap unless teeth are out of line anatomically.
 For periapical radiographs, the long-cone paralleling
technique most accurately projects the alveolar bone level.

Periapical radiographs frequently do not reveal the correct relationship between

the alveolar bone and the CEJ, particularly in cases in which a shallow palate or
floor of the mouth does not allow ideal placement of the periapical film
• Bite-wing projections offer an alternative that better
images periodontal bone levels.

• The film is placed behind the crowns of the upper and

lower teeth parallel to the long axis of the teeth.

• The x-ray beam is directed through the contact areas of

the teeth and perpendicular to the film, it allows
evaluation of the relationship between the interproximal
alveolar crest and the CEJ without distortion.

• If the periodontal bone loss is severe and the bone level

cannot be visualized on regular bite-wing radiographs,
films can be placed vertically to cover a larger area of the
jaws.
 • Early destructive changes of bone that do not
remove sufficient mineralized tissue cannot be
captured on radiographs.

• The earliest signs of periodontal disease must be

detected clinically.

• In periodontal disease the interdental bone

undergoes changes that affect the lamina dura,
crestal radiodensity, size and shape of the
medullary spaces, and height and contour of the
bone.

• Bone destruction of facial and lingual surfaces is

masked by the dense root structure.

• Bone destruction on the mesial and distal root

surfaces may be partially hidden by
superimposed anatomy.

• Interdental bone loss may continue facially and

or lingually to form a troughlike defect that could
Interdental lesion that extends to the facial or
lingual surfaces in a troughlike manner.
be difficult to see radiographically.
 Periodontal tissue destruction include the following:

fuzziness and disruption of lamina dura continued periodontal bone loss and
widening of the periodontal space
results in a wedge-shaped radiolucency
at the mesial or distal aspect of the crest
 Periodontal tissue destruction include the following:

subsequently, the destructive process the height of the interdental septum

extends across the alveolar crest thus is progressively reduced by the
reducing the height of the interdental extension of inflammation and the
bone resorption of bone
• Seen as irregular areas of reduced
density on the alveolar bone crests.

• Craters are generally not sharply

demarcated but gradually blend
with the rest of the bone.

• Conventional radiographs do not

accurately depict the morphology
or depth of interdental craters,
which sometimes appear as vertical
defects.
Invasion of the bifurcation and trifurcation of
multirooted teeth by periodontal disease.

The denuded furcation may be visible

clinically or covered by the wall of the pocket.

The extent of involvement is determined by

exploration with a blunt probe, along with a
simultaneous blast of warm air to facilitate
visualization.

Furcation involvements have been classified

as grades I, II, III and IV according to the
amount of tissue destruction.
 The typical radiographic appearance of the
periodontal abscess is a discrete area of
radiolucency along the lateral aspect of the root.
Localized aggressive (formarly
“localized juvenile”) periodontitis is
characterized by the following:

1. Initially, bone loss in the maxillary and

mandibular incisor and/or first molar
areas, usually bilaterally, resulting in
vertical,arclike destructive patterns

2. As the disease progresses, loss of

alveolar bone may become generalized
but remains less pronounced in the
premolar areas
Can produce radiographically detectable changes in the thickness
of the lamina dura, morphology of the alveolar crest, width of the
PDL space, and density of the surrounding cancellous bone

PHASE:
• INJURY PHASE - produces a loss of the lamina dura that may be
noted in apices, furcations, and marginal areas.
This loss of lamina dura results in widening of
the PDL space

• REPAIR PHASE - widening of the PDL space, which may be

generalized or localized

More advanced traumatic lesions may result in deep angular

bone loss, which, when combined with marginal inflammation,
may lead to intrabony pocket formation. In terminal stages, these
lesions extend around the root apex, producing a wide,
radiolucent periapical image (cavernous lesions).
• offer several advantages over conventional film-based
radiographs in clinical dentistry

• Two major digital intraoral systems are

currently available:

1. The first system uses charge-coupled devices

(CCDs) or complementary metal oxide
semiconductor (CMOS) receptors as
detectors

2. The second system uses photostimulable

phosphor (PSP) plates as detectors
• Once captured and displayed, computer software can be used to
enhance the digital image and increase its diagnostic efficacy.

ADVANTAGES OF INTRAORAL DIGITAL RADIOGRAPHY INCLUDE:

• the speed of image capture and display;

• low x-ray exposure;
• ability to manipulate the image and maximize diagnostic
efficacy;
• use of digital tools;
• improved patient education;
• easy of storage, transfer, and copying;
• seamless integration with electronic patient record
management or other software...
• In the last decade, cone beam computed
tomography (CBCT) has revolutionized
the field of oral and maxillofacial imaging.
• CBCT offers many advantages over
conventional radiography, including the
accurate three-dimensional imaging of
teeth and supporting structures
• Quantitative measurment of disease is based on indices system.

• An effective index system should be quick and easy to use, with

minimal instrumentation.

• CPITN
• PI – Silness & Löe
• PI – Green & Vermillion
• GI – Silness & Löe
• PBI – Muhlemann
• PDI - Ramfjord
 • it determines not only the severity of gingivitis and periodontitis,
but also provides data concerning the extent of therapy that is
necessary
• examination with special probe
• taken only by sextants
• DISADVANTAGE: attachment loss due to recession is not discerned

CODE CPI TN TREATMENT PACKAGES

0 healthy
1 Bleeding on probing 1 Oral hygiene instruction

2 Supra and/or subgingival calculus latrogenic marginal irritation 2 1 + calculus removal

3 Shallow pockets up to 5mm
4 Deeper pockets from 6mm 3 1 + 2 + complex treatment
• by Löe & Silness
• the assesment of the gingival condition
• records qualitative changes in the gingiva
• bleeding is assesed by probing gently along the
wall of soft tissue of the gingival sulcus
 SCORE INTENSITY OF BLEEDING
0 No bleeding
1 A single discreet bleeding point
2 Several isolated bleeding points or a single line of blood appears
3 The interdental triangle fills with blood shortly after probing
4 Profuse bleeding occurs after probing – blood flows immediately into the marginal sulcus

• by Muehlemann in 1975.
• This index permits both immediate evaluation of the patient’s gingival
condition and his motivation, based upon the actual tendency of the
gingival papillae.
• A periodontal probe is inserted into the gingival sulcus at the base of the
papilla on the mesial aspect, then moved coronally to the papilla tip. This
is repeated on the distal aspect of the papilla.
 by Ramfjord in 1959.

OBJECTIVES:
1. To assess prevalence and severity of gingivitis and Periodontitis within the individual dentitions
and in population groups.
2. To provide an accurate basis for longitudinal studies of periodontal disease.
3. To provide a meaningful basis for estimate of need for periodontal therapy in selected population
groups.
4. To provide accurate recordings for clinical trials of preventive and therapeutic procedures in
periodontics.
5. To provide measurable reference data for assessment of correlations with factors of potential
significance in the etiology of periodontal disease.

The most important feature of PDI is measurement of the level of the periodontal attachment
related to the CEJ of the teeth.
1. plaque component
2. calculus component
3. gingival and Periodontal component

• All the three components will be scored separately

using six Ramfjord selected teeth:
• The criteria ranged from:
0 123 456
NORMAL GINIGIVITIS PERIODONTITIS

• All areas (M, D, B, L) is scored as a one unit.

• Only full erupted teeth are scored .

GINGIVITIS:
SCORE CRITERIA
0 negative
1 mild gingivitis involving the free gingiva
2 moderate gingivitis involving the free and attached
gingiva
3 severe gingivitis with hypertrophy and hemorrhage
• when one tooth has probing depths that meet
the following criteria, the gingivitis score is
disregarded and only the periodontal disease
portion of the index is used for that tooth

SCORE CRITERIA
4 pocket depths on two or more of the surfaces of
the tooth measure up to 3mm apical to the CEJ

5 pocket depths on two or more surfaces of the

tooth measure 3-6mm apical to the CEJ

6 pocket depths on two or more surfaces of the

tooth measure more than 6mm apical to the CEJ
 • the surfaces scored are the facial, lingual, mesial and distal.
• instruments used: mouth mirror and a dental explorer

SCORE CRITERIA
0 no plaque
1 plaque present on some but not on all
interproximal, buccal, and lingual surfaces
of the tooth
2 plaque present on all interproximal,
buccal, and lingual surfaces, but covering
less than one half of these surfaces
3 plaque extending over all interproximal,
buccal and lingual surfaces, and covering
more than one half of these surfaces
Scoring of plaque is done after staining with Bismarck Brown solution. Bismarck brown solution is
placed in a dappen dish and two Richmond cotton pellets are placed in the dish until they appear
completely saturated with the solution.

One cotton pellet is removed with a cotton plier and touched gently on to the
lingual and buccal surfaces of the mandibular teeth.

The second pellet is touched on to the palatal and buccal surface of the maxillary teeth. The
occlusal surfaces are also rubbed with the pellet. The second pellet is touched on to the palatal
and buccal surface of the maxillary teeth.

The occlusal surfaces are also rubbed with the pellet. So the disclosing flows over all the surfaces
of the teeth. The patient is then instructed to spit and rinse thoroughly twice. The scoring is then
done, by noticing the stained surfaces.
 CALCULATION:
• the Calculation score per tooth are totaled and then divided by the
number of teeth examined to yield the calculus score person
SCORE CRITERIA

0 absence of calculus

1 supragingival calculus extending only slightly below

the free gingival margin (not more than 1 mm).

2 moderate amount of supragingival and sub gingival

calculus or sub gingival calculus alone.

3 an abundance of supra gingival and sub gingival

calculus.
 The probe should be held with alight grasp the end of the probe should be placed against the
enamel surface coronally to the margin of the gingival so that the angle formed by the working
end of the probe and long axis of the crown of the tooth is approximately 450.

Minimal force should be used to pass the probe in an apical direction maintaining contact with
the tooth. The probe should always be pointed towards the apex of the tooth or the central axis
in case of multirooted teeth.

The buccal measurements should be made at the middle of the buccal surfaces.

The mesial measuring should be made of the buccal aspect of the interproximal contact area
with neighboring tooth present and the probe pointing in the direction of the long axis o the
tooth to he scored.