Drg. Lies - Diagnosos & Prognosis

Diagnosis
Penyakit Periodontal
Dr. Lies Zubardiah, drg., SpPerio
07/28/2020 Diagnosis & Prognosis 1

Diagnosis
• FIRST VISIT
• SECOND VISIT
• LABORATORY AIDS TO CLINICAL DIAGNOSIS

FIRST VISIT
• Overall Appraisal of the Patient

• Medical History
• Dental History
• Intraoral Radiographic Survey
• Casts
• Clinical Photographs
• Review of the Initial Examination

SECOND VISIT
• Oral Examination
• Examination of the Teeth and Implants
• Examination of the Periodontium

Proper Diagnosis
• Essential to intelligent treatment
• Periodontal diagnosis should first determine
whether disease is present
• Identify its type, extent, distribution, severity
• Provide an understanding of the underlying
pathologic processes and its cause

Three broad categories diagnosis
1. The gingival diseases

2. The various types of periodontitis
3. The periodontal manifestations of systemic
diseases

Gingival Diseases
• Chronic marginal gingivitis
• Acute necrotizing ulcerative gingivitis
• Acute herpetic gingivostomatitis
• Allergic gingivitis
• Gingivitis associated with skin diseases
• Gingivitis associated with endocrine-metabolic disturbances
• Gingivitis associated with hematologic-immunologic
disturbances
• Gingival enlargement associated with medications
• Gingival tumors

Features of Types of Periodontitis
Paramet Prepube
Chronic Aggressive LAP NUP
er rtal
Age
35+ 20–35 <11 11–19 15–35
(years)
Moderate to Scanty to
Calculus Scanty Moderate Scanty
abundant moderate
Disease
progressi Slow Rapid Rapid Rapid Rapid
on
Generalized;
Generalized; Primary M1, incisors, no
Distributi associated w/
no consistent molars, more than two ?
on etiologic
pattern incisors other teeth
factors
US: 4%-5%
Prevalen US: >50% Sri
Sri Lanka: ? <0.50% ?
ce 07/28/2020 Lanka: 81%
11% Diagnosis & Prognosis 8
Pre-
Parameter Chronic Aggressive LAP NUP
pubertal
Familial No ? Yes Yes ?

tendency
More
Gender
severe in ? ? ? ?
distribution
men
PMN/macropha
No Yes Yes Yes Yes
ge defects
Association
with systemic No Some cases Yes Yes Yes
problems
Response to
Very good Variable Poor Good Variable
therapy
• LAP, Localized aggressive periodontitis
(formerly “localized juvenile periodontitis”
[LJP)
• NUP, necrotizing ulcerative periodontitis
• PMN, polymorphonuclear leukocyte

First Visit
Overall Appraisal of the Patient

Includes consideration of :
• The patient's mental
• Emotional status
• Temperament
• Attitude
• Physiologic age

Medical History
• Obtained and can be supplemented by

pertinent questioning at subsequent visits
• The health history (obtained verbally by
questioning/ recording their responses on a
blank piece of paper/ by means of a printed
questionnaire the patient completes
Figure 30-1 Medical history form from the American Dental Association.

The importance of the medical history
The patient should be made aware of
(1) the possible role that some systemic diseases,
conditions, or behavioral factors may play in the cause
of periodontal disease;
(2) the presence of conditions that may require special
precautions or modifications in the treatment
procedure (see Chapter 37); and
(3) the possibility that oral infections may have a powerful
influence on the occurrence and severity of a variety
of systemic diseases and conditions (see Chapter 28)

The medical history should include :
1
a. Is the patient under the care of a physician
b. what is the nature and duration of the
problem and the therapy?
c. The name, address, and telephone number
of the physician should be recorded, since
direct communication with pasien may be
necessary.

2
a. Details on hospitalizations and operations,
b. including diagnosis , kind of operation, and
c. untoward events, such as anesthetic,
hemorrhagic, or infectious complications,
should be provided.

3. A list of all medications
 All the possible effects of these medications
 should be carefully analyzed to determine their effect on
the oral tissues
 to avoid administering medications that would interact
adversely with them
 the dosage and duration of therapy with anticoagulants
and corticosteroids
 Patients taking the family of drugs called
bisphosphanates (e.g., Actonel, Fosamax, Boniva, Aredia,
and Zometa)  osteoporosis, osteonecrosis of the jaw

4
• History of all medical problems
(cardiovascular, hematologic, endocrine, etc),
• including infectious diseases, sexually
transmitted diseases, and high-risk behavior
for human immunodeficiency virus (HIV)
infection.

5. Any possibility of occupational disease should

be noted
 Abnormal bleeding tendencies  nosebleeds
 prolonged bleeding from minor cuts,
spontaneous ecchymoses, tendency toward
excessive bruising, excessive menstrual
bleeding
 These symptoms should be correlated with
the medications the patient is taking
7. History of allergy 

 hay fever, asthma, sensitivity to foods
 sensitivity to drugs (aspirin, codeine, barbiturates,
sulfonamides, antibiotics, procaine, laxatives)
 Sensitivity to dental materials (eugenol, acrylic resins)
8. Onset of puberty, menopause, menstrual disorders,
hysterectomy, pregnancies, and miscarriages.
9. Family medical history, including bleeding disorders
and diabetes.

Dental History
Current Illness:
• Bleeding gums; loose teeth; spreading of the teeth
 spaces where none existed before
• Foul taste in the mouth; itchy feeling in the gums 
relieved by digging with a toothpick
• Pain of varied types and duration (constant, dull,
gnawing pain)
• Dull pain after eating; deep, radiating pains in the
jaws; acute throbbing pain; sensitivity when chewing
• Sensitivity to hot and cold; burning sensation in the
gums; extreme sensitivity to inhaled air.
Dental history reference to :
1 Visits to the dentist (frequency, date of the most

recent visit, nature of the treatment, oral
prophylaxis/cleaning by a dentist/ hygienist,
frequency and date of most recent cleaning)
2 Patient's oral hygiene regimen (toothbrushing
frequency, time of day, method, type of toothbrush
& dentifrice, interval at which brushes are replaced.
Other methods for mouth care (mouthwashes,
interdental brushes/ other devices, water irrigation,
dental floss).

3 Orthodontic treatment (duration & approximate

date of termination)
4 Pain in the teeth/ gingiva, the manner pain is
provoked (nature, duration, the manner in which it
is relieved)
5 Gingival bleeding, whether it occurs
(spontaneously, on brushing/eating, at night/ with
regular periodicity); whether it is associated
(menstrual period/ other specific factors); the
duration of bleeding & the manner in which it is
stopped.
6 Bad taste in the mouth and areas of food

impaction
7 The teeth feel “loose” / insecure; difficulty in
chewing; tooth mobility
8 Dental habits (grinding/ clenching, during the
day/ at night; teeth or jaw muscles feel “sore”
in the morning; tobacco smoking /chewing,
nail biting, biting on foreign objects

9 History of previous periodontal problems (nature

of condition & previously treated, type of
treatment: surgical/ nonsurgical, approximate
period of termination of previous treatment.
Opinion patient about recurrence of previous
disease
10 Removable prosthesis (enhance/ detriment to the
existing dentition or the surrounding soft tissues)
11 Implants replacing any of the missing teeth

Intraoral Radiographic Survey
• The radiographic survey should consist of a

minimum of 14 intraoral films and four
posterior bite-wing films (Figure 30-2).

Intraoral Radiographic Survey

Panoramic radiographs
• Simple and convenient method of obtaining a survey view
of the dental arch and surrounding structures (Figure 30-3)
• Helpful for detection developmental anomalies, pathologic
lesions of teeth and jaws, fractures, dental screening
examinations of large groups
• Provide an informative overall radiographic picture of the
distribution and severity of bone destruction in
periodontal disease
• A complete intraoral series is required for periodontal
diagnosis and treatment planning.

Figure 30-3 Panoramic radiograph showing temporomandibular
joints and “cystic” spaces in the jaw. Areas of periodontal bone
loss are not seen in detail. (Compare with Figure 30-2.)

Casts
• Useful adjuncts in the oral examination
• Indicate position of gingival margins (recession),
position & inclination of teeth, proximal contact
relationships, food impaction areas
• Provide a view of lingual-cuspal relationships
• Important records of dentition before altered by
treatment
• Serve as visual aids in discussions with the patient,
pretreatment and posttreatment comparisons,
reference at recall visits
• Helpful to determine position implant placement.
Clinical Photographs
Color photographs
• Useful for recording appearance of tissue
before/ after treatment.
• Depict gingival morphologic changes
(mucogingival problems: gingival recession,
frenum involvement, papilla loss)

Review of the Initial Examination
• If no emergency care  instructed for second visit
• Before this visit examination: radiographs,
photographs, casts
• The casts are checked for evidence of :
 abnormal wear, plunger cusps, uneven marginal
ridges
 malposed/extruded teeth, crossbite relationships
 other conditions (could cause occlusal
disharmony/food impaction)  Such areas are
marked on the casts
Radiographic Aids in the Diagnosis of
Periodontal Disease

Radiographs
• Valuable for diagnosis periodontal disease,
estimation of severity, determination of
prognosis, evaluation of treatment outcome.
• Adjunct to the clinical examination, not a
substitute for it.
• Demonstrate changes in calcified tissue; reveal
reflect the effects of past cellular experience
on the bone and roots

Normal Interdental Bone
• Evaluation of bone changes based mainly on the

appearance of the interdental bone
• The interdental bone normally is outlined by a thin,
radiopaque line adjacent to the periodontal ligament
(PDL) and at the alveolar crest, referred to as the
lamina dura (Figure 31-1)
• Lamina dura represents the cortical bone lining the
tooth socket, the shape and position of the root,
changes in the angulation of the x-ray beam produce
considerable variations in its appearance.
Figure 31-1 Crest of interdental bone normally parallel
to a line drawn between the CEJ of adjacent teeth
(arrow). Note also the radiopaque lamina dura around
the roots and interdental bone.

• Width and shape interdental bone & angle of the
crest normally vary, according to the convexity of
the proximal tooth surfaces and the level of the CEJ
of approximating teeth
• Faciolingual diameter of the bone related to the
width of proximal root surface
• The angulation of crest interdental septum
generally parallel to a line between the CEJs of the
approximating teeth (see Figure 31-1)
• When there is a difference in the level of the CEJs,
the crest of the interdental bone appears angulated
rather than horizontal.
Radiographic Techniques
• Conventional radiographs  periapical & bite-wing
projections offer most diagnostic information & commonly
used in the evaluation of periodontal disease
• To properly and accurately depict periodontal bone status,
proper techniques of exposure and development are
required
• The bone level, pattern of bone destruction, PDL space
width, the radiodensity, trabecular pattern, marginal
contour of interdental bone, vary by modifying exposure
and development time, type of film, and x-ray angulation
• Standardized, reproducible techniques required to obtain
reliable radiographs for pretreatment and posttreatment
comparisons
Prichard, established 4 criteria to determine
adequate angulation of periapical radiographs:
1 The 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.
Periapical radiographs
The long-cone paralleling technique most accurately projects the
alveolar bone level
The bisection-of-the-angle technique elongates the projected
image, making:
 the bone margin appear closer to the crown
 the level of the facial bone is distorted more than that of the
lingual
Inappropriate horizontal angulation results in:
 tooth overlap, changes the shape of the interdental bone
image
 alters the radiographic width of the PDL space & the
appearance of the lamina dura
 may distort the extent of furcation involvement (figure 31-2)
Figure 31-2
Comparison of
long-cone
paralleling and
bisection-of-the-
angle techniques
A, Long-cone
paralleling
technique,
radiograph of dried
specimen..

Figure 31-2B Comparison of long-cone paralleling and
bisection-of-the-angle techniques
B, Smooth wire is on margin of the facial plate and knotted wire
is on the lingual plate to show their relative positions

Figure 31-2C Comparison of long-cone paralleling and
bisection-of-the-angle techniques.
C, Bisection-of-the-angle technique, same specimen as A and B.

D, Bisection-of-the-angle technique. Both bone margins are
shifted toward the crown, the facial margin (smooth wire) more
than the lingual margin (knotted wire), creating the illusion that
the lingual bone margin has shifted apically.

Periapical radiographs
frequently do not reveal the correct relationship between the alveolar bone and the
CEJ
In 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
Bite-wing radiographs  film placed behind the crowns of the upper and lower
teeth parallel to the long axis of the teeth
The x-ray beam directed through the contact areas of the teeth and perpendicular
to the film.
Bite-wing films allows the evaluation of the relationship between the interproximal
alveolar crest and the CEJ without distortion
If periodontal bone loss is severe and bone level cannot be visualized on regular
bite-wing radiographs, films can be placed vertically to cover a larger area of the
jaws
More than two vertical bite-wing films might be necessary to cover all the
interproximal spaces of the area of interest.

of periapical
(A) and bite-wing (B)

radiographs. Angulation of the
x-ray beam and the film on
the periapical radiograph
distort the distance between
the alveolar crest and the
cementoenamel junction (CEJ)
(compare a-b versus a1-b1). In
contrast, the projection
geometry of the bite-wing
radiograph allows a more
accurate depiction (a2-b2) of
the distance between the
alveolar crest and the CEJ (a-
b).

Figure 31-3 Schematic diagram
Periapical Bite-wing

Figure 31-4 Periapical radiographs from full-and bite-
wing mouth series of patient with periodontitis
Periapical Bite-wing

Figure 31-5 Vertical bite-wing films can be used to
cover a larger area of the alveolar bone

Bone Destruction In Periodontal Disease
• Early destructive changes of bone that do not
remove sufficient mineralized tissue cannot be
captured on radiographs
• Therefore slight radiographic changes of the
periodontal tissues suggest that the disease
has progressed beyond its earliest stages
• The earliest signs of periodontal disease must
be detected clinically

Bone Loss
• The radiographic image tends to

underestimate the severity of bone loss
• The difference between the alveolar crest
height and the radiographic appearance
ranges from 0 mm to 1.6 mm,[27] mostly
accounted for by x-ray angulation.

Amount of bone loss
• Radiographs are an indirect method for determining
the amount of bone loss in periodontal disease
• they image the amount of remaining bone rather
than the amount lost
• The amount of bone lost is estimated to be the
difference between the physiologic bone level and
the height of the remaining bone.
• The distance from the CEJ to the alveolar crest in
adolescents, suggest a distance of 2 mm to reflect
normal periodontium; this distance may be greater in
older patients.
Distribution
• The distribution of bone loss is an important
diagnostic sign
• It points to the location of destructive local
factors in different areas of the mouth and in
relation to different surfaces of the same
tooth.

Pattern of Bone Destruction
• Periodontal disease  interdental bone
undergoes changes  affect the lamina dura,
crestal radiodensity, size & shape of the
medullary spaces, height & contour of the bone.
• Height of interdental bone may be reduced 
the crest perpendicular to the long axis of the
adjacent teeth (horizontal bone loss; Figure 31-6
), or angular or arcuate defects (angular, or
vertical, bone loss; Figure 31-7)
Figure 31-6 Generalized horizontal bone loss

Figure 31-7 Angular bone loss on first molar with
involvement of the furcation

Radiographs
• do not indicate the internal morphology or depth of
craterlike defects
• do not reveal the extent of involvement on the facial and
lingual surfaces  Bone destruction of facial and lingual
surfaces is masked by the dense root structure, and bone
destruction on the mesial and distal root surfaces may be
partially hidden by superimposed anatomy, such as a dense
mylohyoid ridge (Figure 31-8).
• In most cases, it can be assumed that bone losses seen
interdentally continue in either the facial or the lingual
aspect, creating a troughlike lesion.

Figure 31-8 Angular bone loss on mandibular molar
partially obscured by dense mylohyoid ridge.

Radiographs
• Dense cortical facial and lingual plates of interdental bone
obscure destruction of the intervening cancellous bone 
a deep craterlike defect between the facial and lingual
plates might not be depicted on conventional radiographs
•  To record destruction of the interproximal cancellous
bone radiographically, the cortical bone must be involved
• A reduction of only 0.5 to 1.0 mm in the thickness of the
cortical plate is sufficient to permit radiographic
visualization of destruction of the inner cancellous
trabeculae

Figure 31-9 Interdental lesion that extends to the facial
or lingual surfaces in a troughlike manner

Radiographic Appearance of Periodontal
Disease

Periodontitis
Radiographic changes in periodontitis follow the pathophysiology of
periodontal tissue destruction and include :
1 Fuzziness and disruption of lamina dura crestal cortication
continuity  earliest radiographic change  results from bone
resorption activated by extension of gingival inflammation into
the periodontal bone
Depicting early changes depends greatly on the radiographic
technique, anatomic variations (thickness and density of
interdental bone, position of adjoining teeth)
No correlation between crestal lamina dura in radiographs and the
presence or absence of clinical inflammation, bleeding on
probing, periodontal pockets, or loss of attachment

2 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 (Figure 31-11, B). The apex of the
area is pointed in the direction of the root.
3 The destructive process extends across the
alveolar crest  reducing the height of the
interdental bone. (Figure 31-11, C).
4 The height of the interdental septum is
progressively reduced by the extension of
inflammation and the resorption of bone (
Figure 31-11, D).
Figure 31-11
Radiographic changes
in periodontitis. A,
Normal appearance of
interdental bone.

Figure 31-11
in periodontitis. B,
Fuzziness and a break
in the continuity of
the lamina dura at the
crest of the bone
distal to the central
incisor (left). There are
wedge-shaped
radiolucent areas at
the crest of the other
interdental bone.
Figure 31-11
in periodontitis.. C,
Radiolucent
projections from the
crest into the
interdental bone
indicate extension of
destructive processes.
D, Severe bone loss.

Interdental Craters
• Interdental craters are 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.

Furcation Involvement
• Definitive diagnosis of furcation involvement is made by
clinical examination, which includes careful probing with
a specially designed probe (e.g., Nabers).
• Radiographs are helpful, but root superimposition,
caused by anatomic variations and/or improper
technique, can obscure radiographic representation of FI.
• bone loss is greater than it appears in the radiograph. A
tooth may present marked bifurcation involvement in
one film  but appear to be uninvolved in another
• Radiographs should be taken at different angles to
reduce the risk of missing furcation involvement.

Figure 31-12 A,
Furcation involvement
indicated by triangular
radiolucency in
bifurcation area of
mandibular first molar.
The second molar
presents only a slight
thickening of the
periodontal space in
the bifurcation area.

Figure 31-12
B, Same area as A,
different angulation.
The triangular
radiolucency in the
bifurcation of the first
molar is obliterated,
and involvement of
the second molar
bifurcation is
apparent.

To assist in the radiographic detection of
furcation involvement, suggested:
1
• The slightest radiographic change in the furcation area should be
investigated clinically, especially if there is bone loss on adjacent
roots (Figure 31-13).
2
• Diminished radiodensity in the furcation area in which outlines of
bony trabeculae are visible suggests  furcation involvement (
Figure 31-14).
3
• Whenever there is marked bone loss in relation to a single molar
root, it may be assumed that the furcation is also involved (
Figure 31-15).

Figure 31-13
Early furcation
involvement
suggested by fuzziness
in the bifurcation of
the mandibular first
molar, particularly
when associated with
bone loss on the
roots.

Figure 31-14
Furcation involvement of
mandibular first and
second molars indicated
by thickening of
periodontal space in
furcation area. The
furcation of the third
molar is also involved, but
the thickening of the
periodontal space is
partially obscured by the
external oblique line.
Figure 31-15
Furcation involvement of
the first molar partially
obscured by the
radiopaque lingual root.
The horizontal line across
the distobuccal root
demarcates the apical
portion (arrow), which is
covered by bone, from the
remainder of the root,
where the bone has been
destroyed.
Periodontal Abscess
Typical radiographic appearance  discrete area of

radiolucency along the lateral aspect of the root 
radiographic picture often not characteristic. Due to :
1 The stage of the lesion. In the early stages acute periodontal
abscess extremely painful but no radiographic changes.
2 The extent of bone destruction and the morphologic changes
of the bone.
3 The location of abscess. Lesions in soft tissue wall pocket are
less likely to produce radiographic changes than those deep
in the supporting tissues.
Abscesses on the facial or lingual surface are obscured by the
radiopacity of the root; interproximal lesions are more likely
to be visualized radiographically.
Figure 31-16 Radiolucent area on lateral aspect of root
with chronic periodontal abscess.

Figure 31-17 Typical radiographic appearance of
periodontal abscess on right central incisor.

Figure 31-18
Chronic periodontal
abscess. A,
Periodontal abscess in
the right central and
lateral incisor area.

B, Extensive bone
destruction and
thickening of the
periodontal
ligament space
around the right
central incisor.

Radiographs alone cannot provide
final diagnosis of a periodontal
abscess but need to be accompanied
by careful clinical examination.

Clinical Probing
• Regenerative and resective flap designs and incisions require
prior knowledge of the underlying osseous topography.
• Careful probing of pocket areas after scaling and root planing
often require local anesthesia and definitive radiographic
evaluation of the osseous lesions
• Radiographs taken with periodontal probes or other
indicators (e.g., Hirschfeld pointers) placed into the
anesthetized pocket show the true extent of the bone lesion.
• the attachment level on the radicular surface or interdental
lesions with thick facial or lingual bone cannot be visualized
in the radiograph. The use of radiopaque indicators is an
efficient diagnostic aid

Localized Aggressive Periodontitis
Localized aggressive (formerly “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.

Localized aggressive periodontitis. The accentuated bone destruction
in the anterior and first molar areas is considered to be characteristic
of this disease.
Figure 31-20

Trauma from Occlusion (TFO)
• Trauma from occlusion can produce

radiographically detectable changes in the:
 thickness of the lamina dura,
 morphology of the alveolar crest,
 width of the PDL space,
 density of the surrounding cancellous bone.

Traumatic lesions manifest
• more clearly in faciolingual aspects because mesiodistally
the tooth has the added stability provided by the contact
areas with adjacent teeth.
•  slight variations in the proximal surfaces may indicate
greater changes in the facial and lingual aspects.
• The radiographic changes listed next are not
pathognomonic of trauma from occlusion and must be
interpreted in combination with clinical findings (tooth
mobility, presence of wear facets, pocket depth, analysis
of occlusal , habits)

The injury phase of trauma from occlusion
• 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.
The repair phase of trauma from occlusion results in
• an attempt to strengthen the periodontal
structures to better support the increased loads.
• Radiographically, this is manifested by a widening
of the PDL space, which may be generalized or
localized
Figure 31-21
Widened periodontal
space caused by
trauma from
occlusion. Note the
increased density of
the surrounding bone
caused by new bone
formation in response
to increased occlusal
forces.

• Although microscopic measurements have
determined normal variations in the PDL space
width along the root surface  generally not
detected radiographically.
•  when seen on the radiographs, PDL space
variations in width suggest that the tooth is being
subjected to increased forces.
• Successful attempts to reinforce the periodontal
structures by widening of the PDL space is
accompanied by increased width of the lamina
dura and sometimes by condensation of the
perialveolar cancellous bone.
• More advanced traumatic lesions may result
in deep angular bone loss  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).

Additional Radiographic Criteria
1. Radiopaque horizontal line across the roots.

2. Vessel canals in the alveolar bone
3. Differentiation between treated and

untreated periodontal disease

Figure 31-22
Horizontal lines
across the roots of the
central incisors
(arrows). The area of
the roots below the
horizontal lines is
partially or completely
denuded of the facial
and lingual bony
plates.

Figure 31-23 Prominent vessel canals in the
mandible.

Clinical Risk Assessment
Definitions
• Risk assessment is defined by numerous
components.
• Risk is the probability that an individual will
develop a specific disease in a given period.
The risk of developing the disease will vary
from individual to individual.

Risk factors
• may be environmental, behavioral/ biologic factors that,
when present, increase the likelihood that an individual
will develop the disease.
• Risk factors are identified through longitudinal studies of
patients with the disease of interest.
• Exposure to a risk factor or factors may occur at a single
point in time; over multiple, separate points in time; or
continuously.
• However, to be identified as a risk factor, the exposure
must occur before disease onset.
• Interventions often can be identified and when
implemented, can help modify risk factors.
Categories of Risk Elements for
Periodontal Disease
Risk Factors : Tobacco smoking, Diabetes, Pathogenic
bacteria, Microbial tooth deposits
Risk Determinants/Background Characteristics: Genetic
factors, Age, Gender, Socioeconomic status, Stress
Risk Indicators: HIV/AIDS, Osteoporosi, Infrequent
dental visits
Risk Markers/Predictors: Previous history of periodontal
disease, Bleeding on probing, HIV, Human
immunodeficiency virus; AIDS, acquired
immunodeficiency syndrome

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Diagnosis

Dr. Lies Zubardiah, drg., SpPerio

07/28/2020 Diagnosis & Prognosis 1

• LABORATORY AIDS TO CLINICAL DIAGNOSIS

07/28/2020 Diagnosis & Prognosis 2

• Overall Appraisal of the Patient

07/28/2020 Diagnosis & Prognosis 3

• Examination of the Teeth and Implants

• Examination of the Periodontium

07/28/2020 Diagnosis & Prognosis 4

07/28/2020 Diagnosis & Prognosis 5

1. The gingival diseases

07/28/2020 Diagnosis & Prognosis 6

07/28/2020 Diagnosis & Prognosis 7

Familial No ? Yes Yes ?

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Overall Appraisal of the Patient

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• Obtained and can be supplemented by

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5. Any possibility of occupational disease should

7. History of allergy 

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1 Visits to the dentist (frequency, date of the most

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3 Orthodontic treatment (duration & approximate

6 Bad taste in the mouth and areas of food

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9 History of previous periodontal problems (nature

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• The radiographic survey should consist of a

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• Evaluation of bone changes based mainly on the

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(A) and bite-wing (B)

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• The radiographic image tends to

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