Clinical sessions 2012-2013 intra-oral examination



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CLINICAL SESSIONS


2012-2013

INTRA-ORAL EXAMINATION

The aim of the clinical examination is to identify signs of a possible disease including changes in the color, shape, consistency and height of the gin­giva and changes in other oral structures such as the lips, mucosa, tongue, oropharynx, floor of the mouth, hard and soft palate. It is important to examine both the general aspect of these structures and also any possible localized alteration.


EXAMINATION FOR DENTAL PLAQUE

Examination for plaque is the most useful introduction to the examination of the adjacent peri­odontal tissues due to the inter-relationship between the plaque and inflammatory changes within the tissues. Dental plaque can be detected clinically by:



  1. Visual detection - Plaque can be seen as a white-creamy film on the tooth surface. It is more visible if the tooth has been dried or if the plaque is of sufficient thickness.

  2. Use of instrument - The use of a dental instrument (e.g. periodontal probe) is useful and convenient for plaque detection. The probe is run along the tooth surface in the region of the gingival margin. The presence of plaque is recorded if it can be collected on the probe. This method has an advantage of detecting the plaque in the inter-proximal areas (where the plaque is not immediately vis­ible to the examiner) as well as the plaque of insufficient thickness.

  3. Use of disclosing agents - These are dyes used to stain dental plaque and make it more visible. As color changes in the tissues may be obscured by the dye, it is advisable to examine the periodontal tissues before using the dye.


EXAMINATION OF THE PERIODONTAL TISSUES

Examination of the periodontal tissues is important in the diagnosis and treatment planning.


I-Examination for marginal gingival inflammation

Gingiva should be dried before examination as light reflection from moist gingiva may obscure details. Color, size, contour, consistency, surface texture, position in relation to the cement-enamel junction, cause of bleeding and pain if present should be carefully evaluated and recorded. The gingiva is assessed on the basis of the following parameters:




PARAMETERS

NORMAL ( examples)

DISEASED ( examples)

Color

Coral pink with/without melanin pigmentation

Red, bluish red- cyanotic, whitened.

Contours

Papillary

Papillae fill embrasures, pointed tip, pyramidal

Blunted, bulbous, cratered

Marginal

knife edged

Rolled

Consistency (Tone)

Resilient, firm, non-retractable with air

Edematous, soft & spongy, air retractable

Texture

Stippled

Smooth & shiny (loss of stippling)

Position

At cemento-enamel junction

More coronal - More apical

The common signs of inflammation around the gingival margin are swelling (with change in contour, consistency and texture of the gingiva), redness and bleeding. Swelling and redness of the marginal gingiva can be clear and useful indicators for periodontal inflammation. However, these changes are not always easily detected especially when they are less marked. Furthermore, this method of assessment is based on the superficial changes in the appearance of the marginal gingiva. These changes are dependent on many variables and can only be appreciated subjectively. Thus, it is difficult to achieve standardization between different examiners in the interpretation of these superficial changes. Gingival bleeding on probing is a more consistently reliable method to assess ongoing inflammation in the peri­odontal tissues. It is based on the presence or absence of bleeding from the marginal gingiva, following gentle probing. Placing a periodontal probe inside the gingival sulcus and in contact with the inflamed gingiva is suffi­cient to evoke bleeding. BOP indicates some sort of destruction or ulceration of the sulcular epithelium and bleeding from lamina propria.
Recording BOP:

Bleeding Index = Total number of bleeding points x 100



Total number of teeth x 6

In addition to swelling, redness and bleeding of the inflamed marginal gingiva, other parameters such as probing pocket depth, gingival recession, tooth mobility and bone contour/level (determined by x-ray) are assessed to judge the presence and severity of periodontal disease. Of these parameters, probing pocket depth is perhaps the most objective and recordable one.
II-Periodontal probing

Measuring of the periodontal pocket’s depth should ideally be a normal part of the dental diagnostic visit. Periodontal pockets should be examined for their presence, type and distribution in relation to each tooth in the dentition. This can be done by systematic and careful probing for all surfaces of each tooth with a periodontal probe. During probing, the probe is inserted with a firm, gentle pressure to the bottom of the pocket. A probing force of 25 grams (0.75 Newtons) has been found to be well tolerated and accurate. The shank should be aligned with the long axis of the tooth surface to be probed. The probe should be "walked" around the entire circumference of each tooth. Probing depth is recorded for six locations per tooth (mesio-buccal, buccal, disto-buccal, mesio-lingual, lingual, and disto-lingual).


Williams Periodontal Probe:

Williams periodontal probe is a round, conical-shaped device used to assess the progression and extent of a disease within the periodontal tissues. The probe is marked in millimeters (mm) from its tip as following: 1, 2, 3, 5 then 7, 8, 9 and 10 mm. The spaces between the 3 and 5 mm markings and between the 5 and 7 mm markings are to avoid confusion in the reading of the measurement. The probe may be available with color coding (Figures 1 and 2).





Periodontal Pocket:

Pocket depth is measured as the distance between the gingival margin and the probe tip at the base of the pocket. The average healthy pocket depth is registered at a range of 0-3 mm with no bleeding upon probing. Depths greater than 3 mm can be associated with or without "attachment loss" of the tooth to the surrounding alveolar bone. More than 3 mm pocket depth with attachment loss is a characteristic feature of periodontitis (true periodontal pocket). More than 3 mm pocket depth with no loss of periodontal attachment can be a sign of gingival overgrowth (false pocket) (Figure 3).







Figure 3: Although probe indi­cates probing depth of 5mm measured from the gingival margin, note the probe tip ends at the CEJ. This is a FALSE POCKET


Measuring and recording the probing pocket depth (PPD):

Proper use of the periodontal probe is necessary to maintain accuracy.



  1. Use Williams periodontal probe.

  2. Insert the probe tip down into the gingival sulcus with gentle pressure of 25 gm (no blanching). This results in obscuring a section of the periodontal probe.

  3. Keep the probe parallel to the long axis of the tooth and gently "walk" the probe’s tip along the bottom of the pocket.

  4. The first marking visible above the gingival margin indicates the measurement of the depth of the sulcus/pocket (Figure 4).

  5. Record the measurements at six locations (mentioned above).

  6. Interproximally, the probe should be inserted at 10-15o below the contact area (Figures 5 & 6).

  7. In the periodontal chart, write dash (-) for 1, 2 and 3 mm, and (10+) for more than 10 mm. If the gingival margin is located between two marks, select the greater one (e.g. if it is between 2 and 3 mm, record it 3 mm).


Figure 4: Probe indicates a prob­ing depth of 5 mm measured from the gin­gival margin



Figure 5:

Incorrect angle correct angle



Figure 6: Incorrect angle (Over-angulation)



I
Figure 5
II-Gingival Recession:

Gingival recession refers to the location of the gingival margin apical to the cemento-enamel junction (CEJ) resulting in exposure of the root surface to the oral environment. It is a common problem in adults over the age of 40, but it may also occur starting from the teens. Gingival recession is measured from the visible CEJ to the gingival margin using the periodontal probe as a measuring instrument.


Measuring and recording gingival recession

  1. Determine the location of CEJ.

  2. Measure the distance from GM to CEJ with a periodontal probe at six locations per tooth (Figure 7).

  3. In the corresponding column in the periodontal chart, record gingival recession (CEJ-GM) as follows:

  1. 0 mm if GM coincides with the CEJ.

  2. + value if GM is apical to CEJ (e.g. 4 mm if GM is 4 mm apical to CEJ).

  3. - value if GM is coronal to CEJ (e.g. -2 mm if GM is 2 mm coronal to CEJ (gingival overgrowth/false pocket).


Figure 7: Probe indicates 5 mm of recession measured from GM to CEJ.



Although the probing depth has great significance, it is not enough to make periodontal diagnosis. Why? What is the attachment level? How can you measure it and use it to help your patients?
IV-Periodontal connective tissue attachment:

There are two types of inflammatory changes existing within the periodontal tissues in response to plaque: 1) One type causes no destruction of the peri­odontal connective tissue attachment and its evidence exists at the gingival margins; 2) The other type is destructive as it destroys the periodontal connective tissue attachment and leaves an evidence of previous history of attachment loss (destruction). The evidence of loss of attachment can be in the form recession, pockets, or recession + pockets.

The periodontal probe is suitable for the assessment of loss of attachment. In the clinic, the Williams probe is used. CEJ is the landmark of the attachment loss as it marks the most coronal termination of the periodontal attachment.
Clinical attachment level:

Clinical attachment level (CAL) is the amount of space between the attached periodontal tissues (base of the pocket) and a fixed point, usually CEJ. CAL represents the best measure of disease severity in terms of loss of support for the teeth. Furthermore, it is used to assess the stability of attachment as part of a periodontal maintenance program as it allows the dentist to accurately monitor the progression of disease over time. For more detailed records, CAL may be recorded at 6 locations per tooth (as with probing depth and gingival recession).

CAL is calculated as follows: CAL = (PD) + (CEJ – GM). When the gingival margin coincides with the CEJ (no recession), the loss of attachment and the pocket depth are equal. If the gingival margin is apical to CEJ (+ value), the loss of attachment will be greater than the pocket depth. If the gingival margin is coronal to CEJ (- value), the loss of attachment will be less than the pocket depth (Figure 8).



frame8
-Examination for calculus

Calculus is divided into two types:



1-Supragingival calculus:

It is derived from the plaque which calcifies above the gingival margin. Its mineral salts are obtained from saliva. It is creamy white in color and comparatively easy to remove. Supragingival calculus is easy to recognize, because it is visually apparent.


2-Subgingival calculus:

It commences its calcification subgingivally, irrespective of its final location. At examination, it may be supragingival due to gingival recession occurring after its initial calcification. It derives its mineral salts from the inflammatory fluid of inflamed marginal gingiva. It is dark in color due to the inclusion of blood pigments. Such inflamed gingival margins with their tendency for hemorrhage will contribute to this feature of color as well as providing the mineral salts. Subgingival calculus is comparatively more difficult to remove than supragingival calculus. Often, it is not visible and, therefore, must be detected by feeling it with a suitable instrument.


Importance of calculus:

Calculus makes the task of mechanical plaque control difficult for patients. Therefore, its removal is an essen­tial component of treatment.


VI- Furcation Involvement

For multi-rooted teeth (e.g. molars and pos­sibly premolars), loss of periodontal attachment may involve the root furcation. In those circumstances, furcation involvement must be recorded. Furcation involvement can be readily detected in good periapi­cal or bitewing radiographs. Clinically, it can be confirmed by using the Nabers probe. Furcation involvement is recorded on the basis of class I, II, III and IV according to the Glickman’s classification of furcation involvement as follows:





Class I Involvement: Pocket formation into the fluting of the furca, but the interradicular bone is intact. No gross or radiographic evidence of bone loss. This is recorded on the periodontal chart as ˄




Class II Involvement: Interradicular bone is destroyed on one or more aspects of the furcation, but a portion of alveolar bone and periodontal ligament remains intact. This is recorded on the periodontal chart as





VII- Tooth mobility:

Tooth mobility, if present, is recorded by the Roman numerals I, II or III. Mobility is detected by using the ends of the handles of two instruments (e.g. mirror and periodontal probe).




I

Detectable increased tooth mobility < 1 mm in bucco-lingual direction.

II

Detectable increased tooth mobility > 1 mm, but < 2 mm in bucco-lingual direction.

III

Detectable increased tooth mobility > 2 mm in bucco-lingual direction and/or clinically evident apical movement upon application of force with an instrument handle on the tooth crown directed in an apical direction.




VIII- Radiographic evaluation

Examine the C.M.S radiographs in an orderly sequence so that you do not miss any significant finding. Start with tooth #18 and work your way clockwise to tooth # 48. Assess, identify and record the following:


Plaque Retention Factors:

Assess for visible calculus deposits, caries at or near the gingival margin and defective restorations (overhanging margins, poor contour and open margins).Record the presence of these factors by tooth number and their location (e.g. # 14 (m), 15 (m,d))


Alveolar bone assessment:

Observe the general pattern of bone resorption and notice whether it is horizontal, vertical or combined. Always report your findings by sextant.


Horizontal bone loss (%):

It is necessary to consider the percentage of bone loss that exists radiographically when making the diagnosis. Measure the distance between the CEJ and the alveolar bone crest, estimate the percentage of the bone loss (%) and record sextant by sextant as follows (any significant exceptions may be noted separately):




1.

0% bone loss

Bone level 1.5 mm apical to the CEJ with no signs of loss of crestal density. It suggests normal bone level.

2.

20% bone loss

Bone level between 2 - 4 mm apical to the CEJ. It suggests slight bone loss.

3.

20%-50% bone loss

Bone level > 4 mm, but < 6 mm apical to the CEJ. It suggests moderate bone loss.

4.

50% bone loss

Bone level >6 mm apical to the CEJ. It suggests severe bone loss.


Note: Bone loss may exhibit different severity in different areas of the mouth. This must be taken into consideration while making individual tooth diagnosis.
Loss of crestal bone density

Examine the crestal lamina dura for its continuity. When there is active destructive inflammation, the crestal bone will undergo resorption and will appear less dense (fuzzy) than normal on the radiographs. This appears more obvious on the bitewing films because of the x-ray orientation. Loss of crestal bone density may indicate presence of periodontitis which cannot be ascertained without clinical examination. The isolated areas with loss of continuity are recorded with the tooth number. If more than 3 inter-proximal areas are involved in a sextant, record it with the sextant number of the involved teeth.


Vertical Defects

Note the location, type, and extent of the defects. When you correlate between clinical and radiographic findings, it will be easier and more accurate to interpret vertical defects. Record the presence of vertical defects by tooth number and defect site, for example # 44 (m), # 46 (m,d)


Furcation Radiolucencies

Note the location and extent of any apparent furcation radiolucency and record the tooth number (e.g. # 46, 47). You should correlate this information with the clinical data.


PDL Width

Record any tooth with obvious widening of the PDL space and record the tooth number and involved site (e.g. # 33 (m), 32 (m,d))


Root length/ form/proximity

Record the tooth number for any root abnormality seen radiographically such as short roots dilacerations, any approximated roots and crown to root ratio (C : R).



Clinical crown to root ratio



Other Significant Findings

Any other factors which may be of significance such as periapical pathology, cyst, impacted teeth, etc. may be recorded.






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