Diagnosis of periodontal abnormalities - Periodontology
Diagnosing is the detection and arrangement of symptoms, which can ultimately lead to the determination of the syndrome.
Diagnosis of periodontal abnormalities
Diagnosing is the detection and arrangement of symptoms, which can ultimately lead to the determination of the syndrome. To be able to make a diagnosis for periodontal disease, we must have:
- Knowledge of the healthy and the sick periodontium;
- About knowledge of the causal (etiological) factors.
Various research methods are used for this diagnosis. We look at:
- The gingiva. Among the characteristics of an inflamed gingiva is a red, swollen bleeding gingiva. The bleeding tendency of the gingiva can be determined by probing and mapped on the bleeding index.
- The periodontal and root cement ligamentum. The condition of these two parts can be checked by:
- Measurement of pocket depths;
- Measurement of the mobility of the elements;
- Detection of possible problems in the root split (furcation).
- The alveolar bone. The condition of this can be checked by means of pocket depth measurement and X-ray examination.
In addition to research into the various parts of the periodontium, plaque research is very important. Many periodontal abnormalities are inflammation caused by the presence of dental plaque. The plaque registration is noted as the plaque index.
All information obtained is recorded in a pocket status or periodontium status. Based on this status, a diagnosis and prognosis is made for each dental element. After treatment of the periodontal problem, a new periodontium status is made. By comparing the old and the new measurements, it can be assessed whether the treatment has achieved its purpose or which follow-up treatment is needed (see images below).
Example of a periodontium status.
There are various research methods for periodontal disease. The following are discussed: plaque index, bleeding or gingivitis index, radiographic examination, DPSI, pocket and periodontal status.
Research into the presence of plaque is recorded with the plaque index. The plaque can be made visible with a disclosing liquid or a disclosing tablet. These liquids or tablets contain substances that turn the dental plaque pink. For each element, six places indicate whether or not there is a plaque:
- Mesiolingual or palatal;
- Lingual or palatal;
- Distolingual or palatal.
The number of patches on which plaque occurs can be expressed as a percentage of the total number of teeth: the plaque score. The higher this percentage, the greater the amount of plaque.
The plaque score is calculated as follows: ((number of patches with plaque): (number of teeth 6 x)) x 100%.
The purpose of the plaque index is to be able to show the patient how much plaque he has on his teeth and also in which places. Every check-in session is followed by a plaque registration and the percentage is supposed to decrease in the course of treatment. The plaque index thus contributes to the patient's motivation. In addition, it is a tool for information. The oral hygiene instruction is adapted to the places where plaque can be found (see image below).
Plaque coloring with a disclosing liquid.
Bleeding or gingivitis index
Bleeding of the gingiva is the most important inflammatory criterion. The number of bleeding gingiva areas gives an impression of the number of dental elements with inflammatory problems. Just like with the plaque index, the number of affected areas is registered on a dental status. The number of measured affected areas is expressed as a percentage of the total number of areas. The higher this percentage, the more inflammation sites occur in the mouth (see image below).
Bleeding after probing.
X-rays are an aid to the examination and in the case of periodontal disease they provide information about:
- Degree and direction of bone resorption;
- Problems in the area of root splitting;
- Presence of tartar;
- Overhang of restorations.
Dutch Periodontal Screening Index
The measurement of the pocket depth of an element is a very important part of the mouth examination. Periodic screening takes place with every periodic oral examination: the DPSI score. The pocket depths are scanned along the entire contour of the tooth. The found pocket depth is read against the gingival border. For example, if the gingiva was withdrawn a few millimeters from the enamel cement boundary, the pocket is not measured from the enamel cement boundary, but from the edge of the withdrawn gingiva.
With the DPSI, the mouth is divided into sextants: both in the upper jaw and in the lower jaw the molars on the right, the molars on the left and the front teeth. The highest pocket is traced and recorded per sextant. The highest measured pocket per sextant determines the DPSI score. Based on the established score, the patient is classified in category A, B or C. The category determines which treatment is required.
The term "an observable recession above a sunken pocket" is understood to mean the following: at the place where the sunken pocket was measured, there was also a gingival requirement, so that the enamel-dentin boundary became visible at that measuring location.
Patients screened in categories B and C are being further examined periodically. A pocket status is made for category B patients and a periodontium status for category C patients. A periodontium status is a more extensive pocket status, which also records recessions, mobility and furcations.
The following issues are dealt with in a periodontium status:
- Registration of the missing elements.
- Gingiva recession. This is a move from the gingival border to the apical. The recession of the gingiva is measured both vestibularly and linguistically (palatally) from the enamel cement border to the gingivaline.
- Investigation of the accessibility or patency of the root splits (furcations) with multi-rooted elements.
The periodontal degradation can continue into the furcation area. The furcations can be accessible or even partially or completely transitory. The so-called furcation condition has a major influence on the prognosis of the element, because the space between the roots is difficult to keep clean. A furcation disorder can best be measured using a furcation probe with marking. The round shape makes it easier to read the probe when checking to what extent a furcation is accessible or permeable. With an upper molar three measurements are performed (mesial, distal and buccal), with a lower molar two measurements (buccal and lingual) and with the above (first) premolars two measurements (mesial and distal). When a furcation disorder is detected, parostatus is noted on the parostatus, depending on the degree of accessibility (see images below).
Probing the furcation.
Furcation measurement in a patient.
- The amount of bone loss is recorded on the basis of X-rays. The amount of bone loss around each dental element is stated. A division is made into less than one third of the root length and more than one third of the root length. There is also a separate coding for angular (oblique) bone defects.
- Mobility of the teeth. The visible mobility is noted.
- Pocket depth. This has already been discussed with the DPSI index.
- Plaque and bleeding index.
After all measurements in the periodontium status are noted, a diagnosis can be made. With that diagnosis we must know the difference between healthy and inflamed periodontium. Bleeding tendency and pocket depth are among the most important clinical features of periodontal inflammation. As a guideline, pockets smaller than 4 mm without bleeding are sound after sounding. Inflamed pockets are first and foremost all pockets with bleeding after probing and pockets larger than 4 mm.
The severity of the degradation can also be determined: a distinction is made between gingivitis (inflamed pockets without degradation) and periodontitis (inflamed pockets with loss of supporting tissue). If there are no inflamed pockets, but there is degradation, there is no question of periodontits or gingivitis. We speak of a healthy, but reduced periodontium.