Periodontal Indices and Diagnosis

1. “Eyes can only see what the mind knows”
• Firm knowledge of what constitutes periodontal health, such that any
deviation from normalcy can be identified
• Knowledge of various diseases & classification systems
• Clinical practice Parameters to identify the presence & severity of
disease.
• Investigations
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2. What is Diagnosis?
“The correct determination,
discriminative estimation &
logical appraisal of the
conditions found during
examination, as evidenced by
signs & symptoms of health &
disease”.
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3. Stages in clinical diagnosis...
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Diagnosis
(Diagnostic casts, photographs)
Investigations
Clinical/provisional Diagnosis
Clinical Examination
(Clinical examination of soft & hard tissues, assessment of local risk factors)
History Recording
(Demographic data, C/C, H O P C, D/H, M/H, P/H)

4. Case History recording
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• Demographic data – Name, Age, Gender,
Occupation, socio-economic status, address
• Chief Complaint
• Medical History
• Past Dental History
• Personal History

5. Clinical Examination – Extra oral examination
• Facial Symmetry
• TMJ – Pain, clicking
sounds, jaw
movements
• Lymph Nodes
• Halitosis
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Space infection
TMJ problem – Jaw deviation

6. Clinical Examination – Soft tissue Parameters
Gingiva:
• Colour
• Contour
• Consistency
• Shape
• Size
• Texture
• Position
• Bleeding on Probing
• Pus exudation
Periodontium
• Clinical Attachment
Loss
• Probing Pocket Depth
• Mobility
• Furcation
involvement
• Pathologic Migration
• Tenderness on
percussion.
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Instruments - Mouth mirror, Calibrated probe.
Mucogingival relations
• Width of attached
gingiva (Tension test)
• Recession
• Type of frenal
attachment (Tension
test)
• Vestibular depth

7. • Colour, Contour, Shape,
Size, Texture – checked by
Visual examination
• Position – Checked by
probing.
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Consistency
Bleeding on Probing
Pus exudation

8. Clinical Examination – Hard tissue Parameters
Deposits
• Plaque
• Calculus
• Stains
Tooth related factors
• Wasting diseases (abrasion,
erosion, attrition, facets)
• Occlusal discrepancies
(plunger cusps, premature
contacts)
• Teeth malalignment
• Proximal contacts
• Food impaction/lodgement
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Restorative factors
•Faulty restorations
•Condition of restorations

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10. Gingival diseases
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11. GINGIVITIS
- Method of Examination
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13. Gingivitis - Dental Biofilm-induced
A. Associated with bacterial dental Biofilm only
B. Potential modifying factors of plaque-induced gingivitis
1. Systemic conditions
a) Sex steroid hormones
i) Puberty
ii) Menstrual Cycle
iii) Pregnancy
iv) Oral contraceptives
b) Hyperglycemia
c) Leukemia
d) Smoking
e) Malnutrition
2. Oral factors enhancing Plaque accumulation
a) Prominent sub gingival restorative margins
b) Hyposalivation
C. Drug-influenced gingival enlargements
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14. Gingivitis – differentiation
Plaque –induced gingivitis
Non Plaque-induced gingivitis
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Plaque induced gingivitis
Hypersensitivity reaction to
Tartar control tooth paste
Irregular gingival erosions –
Pemphigus vulgaris

15. Plaque-induced Non Plaque-induced
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Pubertal gingivitis,19 yr old girl
Severe pregnancy gingivitis,
pregnancy tumor with 34,35
Localized atrophic & erosive gingival
Lesions in erosive lichen planus
Generalized atrophic gingivitis

16. Periodontal diseases
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17. Periodontitis
It is a Microbially associated, host mediated
inflammation causing periodontal tissue
destruction
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18. METHOD OF EXAMINATION
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19. • Clinical Attachment Loss
• Probing Pocket Depth
• Furcation involvement
• Mobility
• Pathologic Migration
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Probing Pocket Depth- Walking method
Furcation involvement
-Nabers probe
Mobility
Pathologic Migration

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21. Necrotizing Periodontal diseases
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NP in smoker
NP in HIV patient

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23. Other conditions affecting periodontium
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24. Gingivitis & Periodontitis in systemically compromised patients
Pts diagnosed
with
hematological /
genetic
disorders
Periodontal
destruction with
little or no
evidence of
plaque/calculus
Diagnosis:
Periodontitis
as a
manifestation
of systemic
disease
Palque induced
Gingivitis or
periodontitis
Onset of
DM / HIV
or others
systemic
conditions
Diagnosis:
Gingivitis /
Periodontitis
modified by a
systemic
condition
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Pts diagnosed
with neoplastic
or other
diseases
Lesion arising
from deeper pdl
tissues,
independent of
plaque/calculus
Diagnosis:
Periodontal
manifestation
of systemic
disease

25. Other Periodontal conditions- Periodontal abscess,
endodontic-Periodontic lesions
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Gingival abscess
Periodontal abscess
Endodotic-Periodontic lesion

26. Mucogingival deformities & conditions around teeth
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High Frenal Attachment
Shallow Vestibule
Generalized erosion & abrasion
Generalized recession

27. Traumatic occlusal forces
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Proposed clinical indicators: –
• Fremitus
• Progressive Mobility
• Occlusal descrepancies
• Wear facets
•Tooth migration
• Fractured tooth
•Thermal sensitivity
• Discomfort/pain on chewing
• Widened PDL space
• Root resorption
• Cemental Tear

28. Prosthesis & tooth related factors that modify
or predispose to plaque induced gingival
diseases/ Periodontitis
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Subgingival crown margins
Overhanging resroration
• Subgingival margins
• Occlusal High points
• Overcontours
• Rough surfaces
• Fractured margins
• Overhangs

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31. Basic Periodontal Examination (BPE)
• Careful assessment of Periodontal tissues is an essential
component of patient management
• BPE is a simple and rapid screening tool needed to
indicate whether further examination is needed
• And provide further guidance on the treatment need
• It is a minimum standard of care for initial periodontal
assessment
• Should be used for screening only and not for diagnosis
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32. 34
Instrument

33. CPITN Probe
• It was described by WHO in 1978 (WHO
Probe)
• Used for measurement of pocket depth
• Light-weight - 5 grams
• Ball tip of 0.5 diameter for easy detection of
sub gingival calculus
• Pocket depth is measured through colour
coding of black mark starting at 3.5mm-
5.5mm
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35. 0 No Pockets>3.5mm, no calculus/overhangs, no bleeding after
probing (black band completely visible)
1 No Pockets>3.5mm, no calculus/overhangs, but bleeding after
probing (black band completely visible)
2 No Pockets>3.5mm, but supra – or sub gingival calculus/overhangs,
but bleeding after probing (black band completely visible)
3 Probing depth 3.5 – 5.5 mm ( black band partially visible, indicating
pocket of 4-5 mm)
4 Probing depth > 5.5 mm ( black band entirely within the pocket,
indicating pocket of 6mm or more)
* Furcation involvement
Code 1-3 – Indicated for initial periodontal Therapy – SRP
Code 4, * – Indicated for advanced periodontal Therapy 37

36. Code 0
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1. Coloured band is
completely visible in
the deepest pocket of
the sextant
2. Nil BOP
3. Nil calculus &/or
defective restorative
margins

37. Code 1
1. Coloured band is
completely visible in the
deepest pocket of the
sextant
2. Bleeding on Probing
3. Nil calculus &/or defective
restorative margins
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38. Code 2
1. Coloured band is
completely visible in
the deepest pocket of
the sextant
2. Calculus
(supra/subgingival)
and/or defective
restorative margins
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39. Code 2 Treatment
• OHI
• Scaling
• Correction of defective
margin
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40. Code 3
• Coloured band is partly
visible in the deepest
pocket of the sextant
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41. Code 3-Treatment
• OHI
• Scaling
• Correction of defective
margins
• Root planing
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42. Code 4
• Coloured band
completely disappears
in the deepest pocket of
the sextant
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43. Code 4 treatment
• Referral to a
Periodontist for full
periodontal assessment
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44. Code *
• Furcation involvement or
Loss of Attachment > 7mm
• Treatment = Referral to
Periodontist for full
periodontal assessment
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45. When to record the BPE?
• All the new patients should have the BPE recorded
• For patients with code 0, 1 or 2, the BPE should be recorded at least
annually
• For patients with BPE codes of 3 or 4, more detailed periodontal
charting is required:
- Code 3: record full probing depths ( 6 sites per tooth) in the
sextant(s) where the code 3 was recorded, in addition to recording
the BPE in those sextants with scores 0, 1 or 2
- Code 4: if there is a code 4 in any sextant, then record full probing
depths (6 sites per tooth) throughout the entire dentition
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46. Video link-Probing
https://www.youtube.com/watch?v=
FaCZ-PApG24
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53. CPITN
CODE CRITERIA TREATMENT NEEDS
0 Healthy periodontium TN-0 No need of
treatment
1 Bleeding observed during / after TN-1 Self care
probing
2 Presence of supra- or subgingival TN-2 Professional care
calculus Scaling
3 Pathological pocket 4-5mm. TN-2 Scaling and root
Gingival margin situated on black planning
band of the probe
4 Pathological pocket 6mm or more. TN-3 Complex therapy
Black band of the probe not visible by specially
trained personnel
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54. Advantages of CPITN
• Easy to use
• Universal index thereby allowing international
comparison of data collected
• Useful for describing the prevalence of needs
for different treatment
• Readily acceptable by patient
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55. Gingival Bleeding Index
By Ainamo & Bay, 1975
Detects absence/presence of bleeding
Code 0 = No bleeding after gentle probing
Code 1 = Bleeding within 10 seconds after gentle
probing
Gingival bleeding index is calculated as a % of
affected sites
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56. Recession index by PD Miller
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57. Furcation Index
By Hamp et al, 1975
Furcation defects have been
classified according to the degree
of the bone loss in the furcation,
measured in the horizontal plane.
Degree I = probe penetrates <
2mm into furcation
Degree II = probe penetrates >
2mm but not completely through
Degree III = ‘Through-and-
through’ furcation involvement
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58. Mobility Index
By Grace & Smales, 1989
0 Nil
1 < 1 mm mobility in bucco-lingual direction
2 1-2 mm mobility in bucco-lingual direction
3 >2 mm mobility in bucco-lingual direction +/-
vertical mobility
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60. Conclusion
• Diagnosis should be based on a “Problem-
focused examination”
• Use appropriate clinical parameters &
screening tests
• Treatment Plan should be based upon
“Problem based approach”
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61. BIBLIOGRAPHY
1. Carranza’s Clinical periodontology, 12th edn.
2. Walter B Hall, Decision Making in Periodontology.
3. Wilson & Kornman, Advances in Periodontics.
4. Peter Heasman, Colour Guide Periodontal Therapy, 1st edn, 1997
5. E F Corbet et al . Diagnosis of acute periodontal lesions. Periodontology 2000,
vol 34, 2004, 204-216.
6. I Rotstein et al. Diagnosis, prognosis & decision making in the treatment of
periodontol-endodontic lesions. Periodontology 2000, Vol 34, 2004, 165-203.
7. W. W.Hallman et al. Occlusal analysis, diagnosis & management in the
practice of periodontics. Periodontology 2000, Vol 34, 2004, 157-164.
8. Richard .C. R. Jordan. Diagnosis of periodontal manifestations of systemic
diseases. Periodontology 2000, Vol 34, 2004, 217-229.
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62. 9. AAP 2017 World Workshop Proceedings on classifications of periodontal
& peri-implant diseases & conditions.
10. Shantipriya Reddy, Clinical manual, 3rd edn.
11. FJ Hughes et al, Clinical Problem solving in Periodontology &
Implantology, Vol 1.
12. I Rotstein, JH Simon. The endo- perio lesion: a critical appraisal of the
disease condition: Endodontic Topica 2006, 13, 34-56.
13. T. Dietrich et al, Periodontal Diagnosis in the context of 2017
classification system of periodontal diseases and conditions -
implementation in clinical practice, British Dental journal, Vol 226(1);
Jan 2019.
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