The Complete Periodontal Examination

7/30/2019 The Complete Periodontal Examination

http://slidepdf.com/reader/full/the-complete-periodontal-examination 1/44

GARY C. ARMITAGE



A thorough periodontal examination is acritically important data-collection activitythat is necessary to arrive at a diagnosis anddevelop a treatment plan.



The purpose of this chapter is to itemize anddescribe the basic components of a completeperiodontal examination and briefly reviewtheir importance in the overall care of the

patient.



Prior to conducting the hands-onexamination, the information-gatheringprocess begins with taking medical anddental histories from the patient.

A valuable aspect of this history-takingdiscussion is that it begins to develop thedoctor-patient relationship.



The discussion helps in clarify importantvariables that may affect the periodontalhealth of the patient.

A key component of the history-takingsession is determination of the patient’s chief complaint.

Prior to the examination it is important to

know why the patient is seeking a periodontalevaluation.



With advance knowledge of the chief complaint, the examiner can, during thecourse of the examination, specifically lookfor possible expectations or causes of

patient’s concerns and problems.



Prior to conducting a periodontalexamination it is customary to routinelyinspect the extraoral tissues of the head &neck.

Examination of all non- periodontal tissuesin the mouth should be performed.

Performance of a periodontal examination

is a multi-task activity. The examiner looks for any signs of

periodontal disease or other abnormalities.



In general, an overall inspection is madeduring which changes in color, shape &texture of the gingival tissues are assessed.

An appraisal of potential etiologic &predisposing factors is continuously beingmade during the examination process.



Detailed measurements of probing depthsand clinical attachment loss are taken &recorded.

Finally, the teeth are inspected for occlusalrelationships and restorative needs.



One of the very first things to note during aperiodontal examination is the presence orabsence of disease.

The four most common signs of gingivalinflammation that are routinely observedduring a periodontal examination are:



1. Redness2. Swelling

3. Bleeding on probing

4. Purulent exudate Gingival redness & swelling usually are seen

together and occur first at the gingivalmargin



Without treatment the inflammation caneventually involve the interproximal area andin some cases extend into portions of attached gingiva.



Sometimes the redness associated withgingival inflammation can be subtle.

Healthy gingiva is firm and resilient, whereasedematous tissue is often enlarged andpuffy.

Recognition of the presence or absence of gingival edema helps the clinician determine

if the tissues are healthy or diseased.



It also serves another important purpose-anticipating the response to treatment.

It should also be remembered that not allareas of gingival redness and swelling aredue to periodontal disease, endodonticinfections sometimes drain through theorifice of a periodontal pocket therebymimicking a periodontal abscess.



Bleeding on probing is an objective sign of gingival inflammation; it is either absent orpresent.

Inflamed tissues bleed when gently probedbecause of minute ulcerations in the pocketepithelium and fragility of the underlyingvasculature.



At the initial examination the percentage of sites that exhibit bleeding on probing prior totreatment is a clinically useful piece of information since it provides a full-mouth

pre-treatment assessment of the extent of gingival inflammation.



Purulent exudate can occasionally be found atsites with gingivitis, it is often detected atsites with chronic periodontitis.

Its presence signifies that the site is inflamedand infected.

Highly purulent periodontal abscesses areassociated with rapid and extensive

destruction of bone and surrounding tissues.



During examination, notations should bemade of any deviation from normalperiodontal anatomy such as-

alterations in contour, aberrant frenalattachment and minimal amounts or lack of keratinized gingiva.



Altered gingival contours can be the result of a wide range of factors.

They become clinically important if theycreate esthetic problems, make plaquecontrol difficult or interfere with function.e.g. Drug induced ginival enlargement orsometimes the enlargement is due to unusualanatomic variations.



Mandibular tori can become so large that theyinterfere with chewing or impede access forplaque procedures.

In some patients with long standing chronicperiodontitis, gingiva becomes firm andenlarged referred to as fibrotic and will notdisappear after scaling and root planing.



During examination, notations should bemade about narrow bands or the completeabsence of keratinised gingiva.

Main clinical importance of an adequate zoneof keratinised gingiva is that it is oftennecessary for the patient to comfortablyperform oral hygiene procedures



The gingiva overlying teeth with narrowzones of keratinised gingiva is often thin andis prone to toothbrush induced damagefollowed by recession.

Aberrant frenal attachments are anatomicfeatures in which they become problem whenthey interfere with oral hygiene or other self care procedures.



During the course of a periodontalexamination the clinician should begin todevelop an idea of what etiologic andpredisposing factors are present.

As the examination is being performed theclinician should develop an impression of what modifiable factors might be responsiblefor, or increase the risk for periodontalinfections?



Where are the heaviest deposits of plaqueand calculus?

Are there local factors that can be mightincrease the risk for periodontal infections?

Tooth related factors such as- close roots,palatal-gingival grooves, furcation anatomy,cervical enamel projections, overhangs on

dental restorations and other localcontributing factors should be noticed andrecorded.



It is also important to keep in mind what isknown about potential risk factors for chronicperiodontitis such as- cigarette smoking,poor compliance, aging, psychological stress

and genetic susceptibility.



Assessments of periodontal damage are amandatory component of a completeperiodontal examination.

Measurements taken with caliberatedperiodontal probes are the main way in whichdamage to periodontium is assessed.

Measurements include- probing depths,

clinical attachment loss and gingivalrecession.



Probing depth and clinical attachment lossmeasurements are routinely recorded at sixsites around each tooth

An attempt is made to probe every portion of the gingival crevice or pocket around eachtooth.

In addition to above assessments,

radiographs are a necessary adjunct to athorough periodontal examination.



Probing depth measurements are importantbecause they give a good approximation of periodontal pockets

Knowledge of depth, extent and location of

pockets gives the clinician a good idea wheretherapy is indicated.

Probing depth reduction is often one of the

main goal of many forms of periodontaltherapy.



Clinical attachment loss is the distance fromthe CEJ to the base of probable crevice.

If CEJ is missing because it has beendestroyed by dental caries or has been

removed by placement of a dentalrestoration, another fixed reference point canbe used to measure attachment loss.



Such landmarks include the apical margin of a restoration or the incisal edge of a tooth.

When attachment loss are taken from a fixedlandmark other than the CEJ they are called

relative attachment loss measurements.

These are the best way to assess thepresence or absence of additional periodontal

damage.



Prior to placing patients in the maintenancephase of therapy, clinical attachment lossreadings should be taken since thesemeasurements serve as a baseline from which

future determinations of additionalattachment loss are judged.



Gingival recession is the distance from theCEJ to the gingival margin.

Recession is often of major concern topatients since it is a readily visible

manifestation of periodontal damage and cancause esthetic problems when occur aroundanterior teeth.



Damage from periodontal disease ofteninvolves the furcation areas of multirootedteeth. The severity of furcation involvement isan important factor in developing a treatment

plan for affected sites. Therefore, during a complete periodontal

examination the location and severity of furcation involvements should be recorded.



The final assessment of periodontal damagethat should be recorded during a completeperiodontal examination is abnormal toothmobility.

Although this symptom may have severalcauses other than periodontal infections, lossof alveolar bone from periodontitis is a majorcause of alveolar tooth mobility.



Although the primary focus of a periodontalexamination is the periodontium, the teethalso need to be carefully inspected for dentalcaries, restorative problems and occlusal

discrepancies. Tooth related problems have considerable

importance in the overall periodontaltreatment plan.



Most acceptable charting systems are simple,easy to fill out and read, and contain all of the relevant information collected during theperiodontal examination.

The periodontal chart requires the help of adental assistant who serves as a recorder of the examination findings.



The chart shown has places for assessments of probing depths, the presence or absence of plaque,clinical attachment loss, the presence or absence of bleeding on probing and the distance from the CEJ

to gingival margin.

Assessments of periodontal damage measurementsat six sites around each tooth are usually recorded.



Some examiners prefer to record, as thevery first step, the presence or absence of plaque on each tooth and surface.

The second step is to measure the probingdepth, CEJ to GM distance, and the presenceto absence of BOP



These three pieces of information arecollected virtually at the same time.

There is usually no problem in understandinghow to measure gingival recession i.e. the CEJ

to GM distance when the gingival margin isapical to CEJ.



In addition, there is usually not a problem inunderstanding that the clinical attachmentloss can be obtained by adding the probingdepth to the amount of gingival recession.

The problem occurs when the gingival marginis coronal to CEJ. In this case, the gingivalmargin is in full view of examiner



To determine the CEJ to GM measurement theexaminer must feel for CEJ with the tip of probe and estimate how far coronally the GMis from CEJ.

If GM is at CEJ, then the recording will be 0. If GM is coronal to CEJ recording will be

negative.





After completion of active periodontaltherapy, prior to placing the patient on amaintenance therapy, the examination shouldbe repeated.

The information to be collected is same asthat obtained during the initial examination.



A key purpose of this post-treatmentevaluation examination is to determine if theadministered therapy was successful inarresting the patient’s disease.

The examination also provides baseline datato which all clinical data collected atsubsequent examinations can be compared.

The Complete Periodontal Examination

Documents