Case history & diagnosis in periodontics /certified fixed orthodontic courses by Indian dental academy

Case History And Clinical
Diagnosis in Periodontics

INDIAN DENTAL ACADEMY
Leader in Continuing Dental Education
www.indiandentalacademy.com

Terminology
 Case History: a planned professional conversation
which enables the patient to communicate his/her
symptoms and fears to the clinician and recorded in
the patients own words as to obtain an insight into
the nature of the patient’s illness and his/her attitude
to them.

 Diagnosis: The correct determination,
discriminative estimation and logical appraisal of the
conditions found during examination as evidenced
by signs and symptoms of health and disease.


Principles of Diagnosis
 Specificity: the ability of a test or observation to
clearly differentiate one disease from another

 Sensitivity: the ability of a test or observation to
detect the disease whenever it is present

 Predictive Value: the probability that the test result
(i.e. the proportion of true positive results and true
negative results combined) agrees with the disease
status


Name

 Identification of the Patient
 Builds a better communication rapport with
the patient
 Inspires confidence of the patient in the
clinician


Age

 To recognize age specific diseases
 Juvenile Periodontitis
 Pre Pubertal Periodontitis
 Acute Herpetic Gingivostomatitis
 Acute Necrotizing Ulcerative Gingivitis
 Pubertal Gingival Changes


Sex

 To Recognize sex specific diseases
 Juvenile Periodontitis
 Changes associated in Pregnancy


Occupation

 Certain Occupations are capable of
producing diseases – “Occupational
Hazards”
 Factory workers in metal workshops show gingival
pigmentations
 Lung Cancer in Beedi Workers
 Silicosis in Watch Worker
 Abrasion of anterior teeth in carpenters / tailors


Address

 Future contact with the patients for follow up
appointments
 To recognize area specific diseases
 Fluorosis


Chief Complaint

 The presenting problem of the patient
 Has to be recorded in the patients own words
in 1-2 sentences
 Obtained by asking the patient to describe
the problem for which help is being sought or
reason for visit


History of the Present Illness

 Elaboration of the Chief Complaint
 In case of Pain
 Mode of Onset
 Duration
 Type of pain
 Radiation or localization of the pain
 Severity
 Aggravating and relieving factors
 Whether the patient has taken any medication or has
consulted a doctor


 In case of Lesion  Bleeding Gums
 When the lesion was  Time of onsent
first observed  Spontaneous/ on
 Mode of development brushing/ while eating
 Symptoms  Associated with
Menstrual Cycle or
 Previous Treatment
other specific factors
 Duration of bleeding
 Manner of stopping


Medical History
 Enables the monitoring of medical conditions and the evaluation of
underlying systemic conditions
 Provides a basis for determining whether the dental treatment might affect
the systemic health of the patient
 Provides an initial starting point for assessing the possible influence of the
patient’s systemic health on the patient’s oral health and/or dental treatment
 Importance to be explained to patient – patients often omit information that
they cannot relate to their dental problem.
 Should include:
 If under the care of any physician at the present time.

 Recent / past hospitalizations or operations to rule out any infections,
anesthetic and hemorrhagic complications.
 Any medication being taken at the present time (stress on anticoagulants
and steroids)
 Abnormal bleeding tendencies.

 History of allergies

 Information regarding the onset of puberty in females, menopause,
menstrual disorders, pregnancies


Leukemic Gingival Enlargement
↓

↑
Cyclosporine induced Gingival
Englargment


Dental History
 Any past dental history –
Duration and nature of the
treatment
 Orthodontic treatment –
Duration and termination of
the treatment
 Pain in the teeth or gums
 History of previous
Gingival Enlargement Associated
periodontal problems – with Orthodontic Applicance
Type or treatment
(Surgical/Non Surgical)


Family History
 History of any
hereditary linked
problems
 Diabetes
 Hemophilia
 Hypertension

Diabetes – Gingival Enlargement


Personal History

 Diet
 Smoking / Tobacco use
 Drug use
 Brushing habits
 Parafunctional Habits
 Other habits


Diet

 Whether mixed or vegetarian
 Vegetarian diets – fibrous in nature, stimulate
saliva and have self cleansing action
 Sticky food – increased retention of plaque.


Smoking and Tobacco Use
 Smoking is directly related
to the development of
periodontitis.
 Decreased resistance of
gingiva due to local irritants
and subsequent increase in
plaque formation.
 Smokers Palate – nicotinic
stomatitis characterized by
prominent mucous glands
and inflammation around
the orifices. Diffuse
erythema with cobblestone
appearance. Tobacco Stains
 Smokers Melanosis – brown
flat irregular lesions or map
like configuration.


Bruxism
 The clenching / grinding of the teeth when the
individual is not chewing or swallowing.
 Can be Nocturnal or Diurnal
 Can occur as a rhythmic side to side movement or
through a sustained clench.
 May lead to:
 Tooth wear
 Fractures
 Muscle hypertrophy
 Masticatory myalgia
 Headaches


Clenching
 “Centric Bruxism”
 Repetitive prolonged forceful contact of the
teeth with no or extremely minimal
mandibular movements.
 May result in:
 Isometric muscle changes
 Pathologic changes of the periodontal supporting
structures
 Secondary changes in the TMJ


Lip/Cheek Biting

 May cause excessive scarring of mucosal
surfaces and occasionally malpositioning of
the teeth involved
 Localized malpositioning may in turn result in
functional occlusal interferences and
associated occlusal traumatization and also
keratinization


Tongue Thrusting
 Persistent forceful wedging of the  Determination:
tongue against the teeth particularly  Hold the lips apart and as the patient
in the anterior region to swallow.
 Causes excessive lateral pressure  Check palatal rugae
that may be traumatic to the
periodontium.
 Spreading and tilting of the anterior
teeth with anterior and posterior
open bites.
 Tooth mobility
 Accumulation of food debris at the
gingival margin
 In accentuated tongue thrusters
there is a scalloping of the tongue –
“Heavy Tongue”


Mouth Breathing
 Gingival changes include:
 Erythema
 Edema
 Enlargement
 Diffuse surface to the exposed areas.

 Tests to diagnose mouth breathing:
 Butterfly test
 Water in the Mouth Test
 Double Mirror Test


Extra Oral General Examination
 Build, height and weight of that patient are noted.
 Jaw symmetry: any asymmetry is to be detected as in the case
of facial swelling.
 Lips:
 Note lip color, texture, any surface abnormalities as well as
angular or vertical fissures, lip pits, cold sores, ulcers, scabs,
nodules, keratotic plaques and scares.
 Palpate upper and lower lips for thickening and swelling

 Note Lip seal and competancy of the lips

 TMJ: Note any deviation, clicking sounds while opening and
closing indicative of a TMJ disorder.
 Lymph Nodes:
 Inflammed nodes are tender, palpable and fairly mobile

 Seen in ANUG, Acute Periodontal Abscesses.


Intra Oral General Examination
 Labial and Buccal Mucosa:
 Palpate upper and lower lips for any thickening or swelling.
 Note orifices of minor salivary glands and the presence of fordyces granules.
 Tongue:
 Inspect dorsum for:
 Swelling and ulcers
 Coating
 Variations in color and texture
 Inspect margins for:
 Distribution of papillae
 Crenations and fasiculations
 Depapillated areas
 Fissures, ulcers and keratotic areas.
 Inspect ventral aspect for:
 Varicosities
 Tight frenal attachments
 Stones in Wharton’s Duct
 Ulcers, swellings and red or white patches
 Observe base of the tongue and vallate papillae


 Floor of the Mouth:
 Observe:
 The opening of Wharton’s Duct
 Salivary pad
 Swellings, ulcers or red and white patches
 Pharynx and Tonsils:
 Palpate the tonsils for discharge or tenderness.
 Note restriction of the oropharynx and airway
 Examine the faucial pillars for:
 Bilateral symmetry
 Nodules
 Red and white patches
 Lymphoid aggregates
 Deformities

Examination of the Gingiva
 Color:
 Normal healthy gingiva appears
coral pink or coral pink with
pigmentation
 Factors affecting color are:
 Pigmentation
 Vascularity
 Keratinization
 Gingiva appears:
 White in case of smokers and
trauma
 Pale red in mild inflammation
 Bright red in acute inflammation
 Magenta in chronic inflammation
 Color changes in relation to
marginal, interdental and attached
gingiva are noted. In case all three
components are involved, then it is Normal Gingiva
called “Diffuse”


 Size:
 Corresponds to the sum total of
cellular and intercellular and
vascular supply
 Vascular component is increased
in case of inflammation.
 Cellular components are increased
in case of hyperplasia
 Enlargement may be Chronic inflammatory
“Inflammatory” or “Fibrotic” gingival enlargement
 Contour:
 Normal gingiva has scalloped
contours with knife edge margins
 This configuration is lost when
there is spacing or recession
 In case of inflammation, scalloping
is exaggerated with rounded
margins.

Marginal Gingivitis and Irregular
Gingival Contour


 Consistency:
 Normal gingiva is firm and resilient (except for the free margin), tightly

bound to the underlying bone
 Factors determining consistency:

 Collagenous nature of the lamina propria
 Attachment to the mucoperiosteum
 Gingival Fibers
 Chronic gingivitis: soggy puffiness that pits on pressure
 Acute gingivitis: reffine puffiness and softency

 Fibrosis and long standing inflammation: Firm and leathery consistancy

 Surface Texture:
 Normal gingiva shows presence of stippling (alternating rounded

protuberances and depressions in the gingival surface)
 Stippling is a form of adaptive specialization or reinforcement for function

 Seen in the attached and central portion of the interdental gingiva

 Stippling is absent in infants and in old age and on the lingual surfaces

 Stippling is lost in gingival infections

 Stippling increases on stimluation of the gingiva

 Viewed by drying the gingiva.


 Exudation:
 Adequacy of Attached Gingiva:
 The attached gingiva is continuous with the marginal gingiva and
tightly bound to the underlying bone.
 Prevents to an extent, pocket formation and resists occlusal
forces.
 It is maximum in the incisor region and minimumin the premolar
region
 Tension Test: Ask the patient to bite, pull the lips outward and
side-wards. In case of inadequacy, marginal gingiva moves
downwards due to lack of adequate attachment.
 Frenal Attachment:
 The Frenum is a fold of mucous membrane with enclosed muscle
fibers that attached the lips and cheeks to the alveolar
mucosa/gingiva and underlying periosteum
 Types of frenal attachments:
 Mucosal
 Gingival
 Papillary
 Papillary Penetrating


 Position of the Gingiva:

 Refers to the level at which the gingival margin is
attached to the tooth.
 It is at the level of the Cemento-Enamel Junction
(CEJ) or above.
 In case of recession, it is present in an apical
position
 In case of inflammation, it is present in a coronal
position


Gingival Recession
 Progressive exposure of the
root surface resulting from
apical migration of junctional
epithelium
 Etiology:
 Improper and traumatic tooth
brushing
 Abnormal frenal attachment
 Gingival Inflammation
 Tooth malposition
 Friction from soft tissues
 Recession can be localized or
generalized, diffuse or hidden


 Classification by P.D. Miller:  Classification by Sullivan and Atkins:

 Class I - Marginal tissue recession  Shallow Narrow Recession
that does not extend to the
mucogingival junction  Shallow Wide Recession
 Class II - Marginal tissue recession
that extends beyond the
mucogingival junction  Deep Narrow Recession
 Class III – Marginal tissue recession
that extends beyond the  Deep Wide Recession
mucogingival junction, there is bone
loss and soft tissue loss interdentally
or malposed tooth
 Class IV – Marginal tissue recession
that extends to or beyond the
mucogingival junction with severe
bone and soft tissue loss
interdentally and/or severe
malpositioning of teeth


The Gingival Index
 Developed by Loe H. and Silness J. in 1963.
 Solely for the purpose of assess the severity of gingivitis and its
location in four possible areas of teeth.
 Method:
 The severity of gingivitis is scored on all surfaces of all teeth. The

tissues surrounding each tooth are divided into 4 gingival scoring
units:
 Distal facial papilla
 Facial margin
 Mesial facial papilla
 Entire lingual gingival margin
 A blunt instrument (periodontal probe) is used to asses the
bleeding potential of the tissues.


 Scoring criteria for the Gingival Index:
 0 = Absence of inflammation – Normal Gingiva

 1 = Mild Inflammation, slight change in color, slight edema, No

Bleeding on probing
 2 = Moderate inflammation, moderate glazing, redness, edema

and hypertrophy. Bleeding on Probing
 3 = Severe inflammation, marked redness, ulceration,

spontaneous bleeding
 Calculation of the Index:
 The scores around each tooth are totalled and divided by 4 – the

gingival index for the individual tooth is obtained.
 Totalling al of the scores per tooth and dividing by the number of

teeth examined provides the gingival index score per person
 Inference:
Score of 0.1 - 1.0 = Mild Gingivitis
Score of 1.1 - 2.0 = Moderate Gingivitis
Score of 2.1 - 3.0 = Severe Gingivitis


The Simplified Oral Hygiene Index
 Has two components:
 Simplified Debris index

 Simplified Calculus index

 Mouth is divided in to 6 sextants with only indexed teeth being
examined in each sextant:
 16,11,26,36,31,4

 In case 16 is absent 17 or 15 is examined (Buccal)

 In case 11 is absent 21 is examined (Buccal)

 In case 26 is absent 27 or 25 is examined (Buccal)

 In case 36 is absent 37 or 35 is examined (Lingual)

 In case 31 is absent 41 is examined (Buccal)

 In case 46 is absent 47 pr 45 is examined (Lingual)

 In case there are less that 2 functional teeth in a sextant, the
sextant is not considered.


 Debris Index:  Calculus Index:
 0 = No Debris  0 = No Calculus
 1 = Debris present on  1 = Supragingival
less that ⅓ of the tooth calculus involving less
surface but less than ⅔ than ⅓ of the tooth
and/or the presence of surface.
extrinsic stains.  2 = Supragingival
 2 = Debris present on calculus present upto the
more that ⅓ but less than middle third of the tooth
⅔ of the tooth surface. surface and/or flecks of
 Debris present on ⅔ or subgingival calculus.
more of the tooth surface.  3 = Supragival calculus
involving more than ⅔ of
the tooth surface and/or a
continuous band of
subgingival calculus


 Calculation of Debris and Calculus Indices:
 Debris or calculus index = Total score divided by
the number of teeth examined

 Calculation of Simplified Oral Hygiene Index:
 OHI-S = CI(S) + DI(S)

 Inference:
 0 – 1.2 = Good Oral Hygiene
 1.3 – 3.0 = Fair Oral Hygiene
 3.0 – 6.0 = Poor Oral Hygiene


Periodontal Pockets
 A Pathologically
deepened gingival
sulcus
 If the depth of the William’s Graduated Periodontal Probe
sulcus is greater than
3mm it is considered a ← Probe Revealing
Extent of
pocket Periodontal
 Measured with Pocket

William’s Graduated
Periodontal Probe.


Furcation Involvement
 Extension of the periodontal
disease into the bifurcation ←Furcation Probing
and trifurcation area of multi-
rooted teeth. Human Skull
 Determined using Naber’s Demonstrating
Probe Furcation
 Classification: Involvement ↓
 Grade I : Incipient or early
lesion
 Grade II : Cul-de-sac lesion
 Grade III : Through and
through involvement, complete
inter-radicular bone loss
 Grade IV : Through and
Through Involvement with
exposure of the furcation area
clinically


Hard Tissue Examination
 Teeth Missing: Long span edentulous areas have a
tendency towards mesial migration of teeth distal to
the space. In such cases the distal cusp of the
migrated tooth acts as a plunger cusp, thereby
forcefully lodging food between the extruded
opposite tooth and its adjacent tooth. Thereby
leading to food impaction, gingival inflammation and
bone loss
 Stains or discolorations:
 Pigmented deposits on the tooth surface.
 Primarily esthetic
 Detected visually
 Can be easily removed.


Calculus
 Consists of mineralized bacterial plaque
 Supragingival calculus:
 Visible in the oral cavity
 White or whitish yellow in color
 Hard clay like consistancy
 Commonly seen on the lingual surface of mandibular anteriors and
buccal surface of maxillary molars
 Subgingival calculus:
 Hard and dense
 Dark brown or greenish black in color.
 Firmly attached to the tooth surface.
 Detected by tactile perception with an explorer (No. 17 or 3A)
 Warm air may be used to deflect the gingiva and aid in visualization
of calculus


Supragingival Calculus on Molar Supragingival Calculus on Lingual Surfaces

Extensive Supra and Sub gingival Calculus Subgingival Calculus on Extracted Tooth


Wasting Diseases

 Wasting is defined as any gradual loss of
tooth substance characterized by the
formation of smooth, polished surfaces
without regard to the possible mechanism of
the loss.
 The forms of wasting diseases are:
 Abrasion
 Attrition
 Erosion


 Abrasion
 Loss of tooth substance induced by mechanical wear other than that
of mastication.
 Causes:
 Tooth brushing with an abrasive dentrifice
 Action of clasps on abutment teeth
 Results in saucer shaped or wedge shaped indentations with smooth
shiny surface
 Continued exposure to the abrasive agent, combined with
decalcification of the enamel by locally forming acids may result in
loss of enamel followed by loss of dentin
 Attrition
 Occlusal wear resulting from functional contacts with opposing teeth
 Increases with Increase in age
 Erosion
 Cuneiform defect
 A sharply defined wedge shaped depression in the cervical area of
the facial tooth surface. The long axis of the eroded area is
perpendicular to the vertical axis of the tooth
 The surfaces are smooth, hard and polished
 Causes: decalcification by acid beverages or citrus fruits along with
the combined effect of acid salivary secretion and friction

Pathologic Migration

 Refers to the tooth displacement that results
when the balance between the factors that
maintain physiologic tooth position is
disturbed by periodontal disease
 Causes:
 Trauma from Occlusion
 Pressure from the tongue
 Pressure from the granulation tissue of
periodontal pockets


Mobility
 Grades of Mobility:
 Grade I : Slightly more than
normal
 Grade II : Moderately more
than normal
 Grade III : Severe mobility
facio-lingually and /or
mesiodistally combined with
vertical displacement
 Causes:
 Loss of tooth support
 Trauma from occlusion
 Endo-perio lesions
 Trauma
 Pregnancy Determining Mobility


Proximal Contacts
 Slightly open contacts permits food impaction
 The tightness of contacts should be checked by
means of clinical observation and with dental floss
 Abnormal contact relationships may also initiate
occlusal changes such as:
 Shift in the median line between the central incisors
 Labio-version of the maxillary canine
 Buccal or lingual displacement of the posterior teeth
 And uneven relationship of the marginal ridges


Rotation

 Teeth are rotated
 Mesially
 Facially
 Lingually or palatally

 Favors plaque accumulation


Faulty Restorations
 Overhanging margins of
dental restorations
contribute to the
development of periodontal
disease
 Location of the gingival
margin of the restoration is
directly related to the health
status of the adjacent
periodontal tissues
 Roughness in the Inflammed Papilla due to
subgingival areas is Overhanging Restoration
considered


Malalignment

 Tooth malalignment predisposes to plaque
accumulation and inflammation in children
and predisposes to clinical attachment loss in
adults, especially when associated with poor
oral hygiene
 Open contacts have been associated with
increased loss of alveolar bone, most
probably through food impaction


Occlusal Analysis
 Overbite:
 Seen most often in the anterior region
 May cause impingement of the teeth on the gingiva and food impaction followed
by gingival inflammation, enlargement and pocket formation
 Overjet: an increase in the horizontal distance between the maxillary and mandibular
anterior teeh
 Open Bite:
 Condition occurs most often in the anterior region, although posterior openbites
are occasionally seen
 Reduced means of cleansing by the passage of food may lead to accumulation of
debris, calculus formation and extrusion of teeth
 Cross Bite:
 Overlap of the maxillary teeth by the mandibular teeth
 May be bilateral of unilateral
 May affect only a pair of antagonists
 Causes trauma from occlusion, food impaction, spreading of mandibular teeth,
associated gingival and periodontal disturbances.
 Plunger Cusps:
 Cusps that tend to forcibly wedge food into the interproximal embrasures
 Leads to food impaction and periodontal disease


Trauma from Occlusion
 Primary Trauma from Occlusion:
 Occurs if trauma from occlusion is the primary etiologic factor in periodontal
destruction
 Causes:
 High Fillings
 Insertion of a prosthetic replacement that creates excessive forces on the
abutment and antagonist teeth
 Drifting movement and extrusion of teeth into edentulous spaces
 Orthodontic movements
 Fremitus Test:
 Wet the ungloved finger and place it partially on the gingiva and partly on the
teeth. Ask the patient to bite repeatedly.
 If vibrations are felt it indicated trauma from occlusion.
 Other factors that indicate trauma from occlusion:
 Excessive mobility of teeth
 Radiographically:
 Widened PDL space
 Vertical or angular bone loss
 Infra-bony pockets
 Pathological Migrations


 Secondary Trauma from Occlusion:

 Occurs when the adaptive capacity of the tissues
to withstand occlusal forces is impaired by bone
loss resulting from marginal inflammation


Radiographs
 Provide information
about the distribution
and severity of bone
destruction


Investigations

 Based on the systemic status, various tests
may be indicated.
 Bleeding time determination
 Clotting time determination
 Prothrombin Time estimation
 Biopsies
 Nutritional Status Evaluation
 Hemogram


Diagnosis

 May be:
 Acute or Chronic
 Localized or Generalized
 Inflammation of the gingiva with bleeding on
probing may indicate Gingivitis
 Presence of periodontal pockets, furcation
involvement, recession may indicate
Periodontitis


Prognosis
 The prediction of the duration, course and
termination of the disease and its response to
treatment
 Divided into:
 Overall prognosis
 Individual prognosis
 Further classified as:
 Excellent
 Good
 Fair
 Poor
 Questionable
 Hopeless

Treatment Plan
 Scheduled sequence of therapeutic measures used to cure or arrest the disease process
 Preliminary Phase:
 Treatment of emergencies
 Phase I : Etiotrophic Phase
 Education and motivation of the patient
 Oral Prophylaxis
 Minor Orthodontic Tooth Movement
 Temporary Restorations
 Phase II : Surgical Phase
 Periodontal Surgery
 Root Canal Therapy
 Phase III : Restorative Phase
 Final Restorations
 Prosthetic Therapy
 Fixed Orthodontic Therapy
 Phase IV : Maintainance Phase
 Periodic Recall
 Supportive Periodontal Therapy


Thank You


Juvenile Periodontitis

 Age Group: 15-19 years
 Commonly seen in females
 Distribution: 1st Molars and Incisors
 Lack of clinical inflammation with presence of
deep periodontal pockets
 Distolabial migration of Maxillary Incisors and
Molars


Juvenile Periodontitis


Acute Herpetic Gingivostomatitis

 Age Group: Infants and Children below 6yrs
of age
 Diffuse erythematous shiny involvement of
gingiva and oral mucosa
 Presence of vesicles


Acute Necrotizing Ulcerative Gingivitis

 Seen in adults
 Punched out crater like
depressions at the
crest of the interdental
papilla, may extend up
to the marginal gingiva


Changes in the Gingiva Seen During
Pregnancy
 Pregnancy accentuates the gingival response
to plaque and modifies the resultant clinical
picture
 Bleeding
 Inflammation
 Bright red to Bluish discoloration
 Raspberry like appearance of the interdental and
marginal gingiva
 Pregnancy Tumors: tumor like discrete masses.


Pre Pubertal Periodontitis

 Age Group: Below 11 years of age
 Patient becomes edentulous as there is rapid
destruction of periodontium leading to loss of
teeth
 Associated with Papillon Lefevre Syndrome,
Downs Syndrome, Neutropenia.


Pubertal Changes in the Gingiva

 Exaggerated Response of the gingiva to local
irritants
 Inflammation
 Enlargement
 Bluish-red discoloration
 Edema


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Case history & diagnosis in periodontics /certified fixed orthodontic courses by Indian dental academy

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