Diagnosis of periodontitis

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Periodontal disease refers to a group of inflammatory conditions that affect the tissues around the teeth. The mildest form of periodontal disease is gingivitis and, if left untreated, gingivitis can progress to periodontitis.
Now, the goal of diagnosis is to detect early signs of periodontal disease, treat the condition, and prevent further complications.
The diagnosis of periodontitis is a systematic process subdivided into several parts, including the patient’s medical and dental history; radiographic evaluation, extraoral examination; intraoral examination; and additional diagnostic tests and procedures.
Let’s start with the medical history which is used to identify systemic factors associated with an increased risk of periodontitis.
These include systemic conditions, such as diabetes mellitus, pregnancy, and HIV infection; environmental factors, such as stress, smoking, and inadequate nutrition; and the use of medications associated with gingival enlargement, such as phenytoin, nifedipine, and cyclosporine.
On the other hand, dental history covers important information about the patient’s oral hygiene habits, the regularity of dental visits, previous dental conditions, and current concerns.
Individuals with periodontitis typically complain of swelling, and bleeding of the gingiva; tooth mobility; and bad breath.
After the history is taken, the next step is a radiographic evaluation with a full mouth radiographic survey. This survey should include periapical radiographs showing the apices of all teeth and appropriate bitewings.
The purpose is to identify and measure the loss of alveolar bone, but also to detect local factors that can complicate the course of periodontitis, such as caries and furcation involvement.
Now, switching gears and moving on to the extraoral examination, which refers to the evaluation of the temporomandibular joint, the symmetry of the face, and regional lymph nodes.
This is an important part of the diagnosis because in severe cases, periodontitis can cause facial swelling and enlargement of submental, submandibular, and cervical lymph nodes.
The enlargement of regional lymph nodes is typically associated with severe necrotizing gingivitis and acute periodontal abscess.
The rest of examination is further subdivided into the examination of the oral mucosa, teeth, and periodontium. Now, let’s start with the oral mucosa examination, which is used to detect abnormal changes of the buccal and labial mucosa, tongue, floor of the mouth, palate, tonsils, and oropharynx.
Additionally, when evaluating the condition of the oral mucosa it’s important to note the presence of oral malodor, which is also known as halitosis.
Next, we have the examination of teeth. Here, it’s important to identify four main mechanisms of tooth wear, which include erosion, abrasion, abfraction, and attrition, .
Erosion refers to tooth lesions caused by acids that are not produced by oral bacteria. For example, erosion can be caused by soft drinks or gastric acid.
The next one is abrasion, which is defined as tooth wear caused by mechanical forces such as tooth brushing. On the flip side, abfraction is tooth wear caused by forces that are associated with chewing, biting, and eating, and it’s typically found at the cementoenamel junction.
The last one is attrition, which refers to lesions of a tooth caused by functional contacts with opposing teeth. Other important features of the person’s teeth that should be considered during the teeth examination include dental decay, stains, and calculus, hypersensitivity, tooth mobility, missing teeth, open contacts, occlusal traumas, furcation involvement, and misalignment of the teeth.
Now, moving on to the periodontal examination, which is the most important part of the diagnostic process. When inspecting the periodontium, it’s crucial to be systematic, so no areas are skipped.
First, it’s important to detect the primary cause of periodontitis, the dental plaque. Additionally, make sure to note the presence of subgingival calculus and supragingival calculi.
The next step is the evaluation of the patient’s gingiva, which includes visual inspection and palpation. The goal is to identify changes in size, color, contour, consistency, surface texture and position.
Normally, the gingival margin lies slightly coronal to the cementoenamel junction, but with gingival recession, it shifts apical to the cementoenamel junction.
On the other hand, in gingival hyperplasia, the gingival margin shifts even more coronal to cementoenamel junction. Now, switching gears and moving on to the examination of the periodontium and detection of periodontal pockets.
The most accurate way to detect periodontal pockets is with a periodontal probe. This is a dental instrument that can have small calibrated millimeter markings or color bands which generally represent 1 to 3 millimeter length.
Now, the dental probe is routinely used to measure clinical parameters including periodontal probing depth, clinical attachment loss, gingival recession, and bleeding on probing.
Periodontal probing depth measures the distance from the gingival margin down to the base of the periodontal pocket or sulcus.
In healthy individuals, the pocket depth is one to three millimeters. If the probing depth is greater than 3 millimeters, it is considered as a periodontal pocket.
On the flip side, clinical attachment loss measures the distance between the cementoenamel junction and the base of the periodontal pocket.
The last one is bleeding on probing which is often described as a measurement of the gingival inflammation. Also don’t forget to note areas of suppuration.
Finally, it’s important to note that the accuracy of these measurements depends on several factors, such as the size and design of the probe tip, the amount of force used, the angulation, and the inflammation of the gingival tissue.
Once the periodontal examination is completed, a diagnosis of gingival health/periodontal health, plaque-induced gingivitis, or periodontitis can be determined.
If the diagnosis is periodontitis, it needs to be staged and graded. Staging classifies the severity and extent of the disease based on CAL, amount of bone loss, tooth loss due to periodontitis, probing depth, nature of bone loss, furcation involvement, and case complexity.
The Stage should be based on the worst signs and can range from Stage I, the least severe or complex, to Stage IV which is the most severe or complex.
Stage I is characterized by a slight attachment loss of 1 to 2 mm, or bone loss less than 15%; no tooth loss due to periodontal disease; probing depths of 4 millimeters or less; mostly horizontal bone loss; and no need for complex rehabilitation.
Stage II is characterized by moderate attachment loss of 3 to 4 mm, or bone loss of 15-33%; probing depths of 5 millimeters or less; mostly horizontal bone loss; and no need for complex rehabilitation.
Stage III is characterized by severe attachment of 5 mm or greater, or bone loss over 33%; up to 4 teeth lost to periodontitis; probing depths of 6 millimeters or greater; vertical bone loss greater than or equal to 3 millimeters; class II or III furcation involvements and moderate ridge defects; and no need for complex rehabilitation.
Stage IV is also characterized by severe attachment loss of 5 mm or greater, or bone loss over 33%. However, patients with stage III characteristics who have lost 5 or more teeth due to periodontitis or have complex rehabilitation needs should be classified as stage IV.
Periodontitis is considered localized if less than 30% of the teeth are involved, and generalized if 30% or more of the teeth are involved.
A molar/incisor pattern can also describe the extent and distribution when appropriate. Next, let’s look at grading which indicates the rate of disease progression and response to treatment.
The disease should be classified as Grade A, B or C. The primary criteria for grading is the amount of radiographic bone loss or attachment loss over the past 5 years.
For Grade A: no bone loss or CAL over 5 years; Grade B: less than 2mm loss over 5 years; Grade C: greater than or equal to 2mm loss over 5 years.
When no such direct evidence is available, % bone loss divided by age can be used in conjunction with case phenotype and risk factors to establish the Grade.
Grade A is “slow rate” where the % bone loss divided by age is less than 0.25; Grade B is “moderate rate” where it’s 0.25 to 1.0; Grade C is “rapid rate” where the number is 1.0 or greater.
For case phenotype, Grade A is heavy biofilm with little destruction; Grade B is destruction commensurate with biofilm deposits; and Grade C destruction exceeds expectation given biofilm deposits.
Risk factors include smoking and diabetic control. Risk factors for Grade A disease include a non-smoking patient who is normoglycemic; Grade B risk factors are smoking less than 10 cigarettes/day and an HbA1c less than 7.0%; Grade C risk factors are smoking greater or equal to 10 cigarettes per day and an HbA1c greater or equal to 7.0%.
When evaluating periodontitis, the clinician should assume Grade B and look for reasons to shift down to Grade A or up to Grade C based on evidence and existing risk factors.
Other diagnostic tests like lab tests play a supportive role and can help guide management. Some examples include tests that evaluate immune response, genetic risks, and antibiotic susceptibility.
##Summary Alright, as a quick recap. The diagnosis of periodontitis is a systematic process that starts with the patient’s medical history to help identify systemic conditions and risk factors that are associated with periodontitis.
The next step is dental history, which covers information about oral hygiene habits, the regularity of dental visits, previous dental conditions, and current complaints like pain, swelling, and gingival bleeding.
After that, a radiological exam should be completed and this is followed by extraoral examination and intraoral examination.
The most important part of the diagnostic process is the periodontal exam. The periodontal examination starts with the detection of dental plaque and calculus and it proceeds with the evaluation of the gingiva.
When examining the condition of the gingiva, it’s important to detect changes in size, color, contour, consistency, surface texture, and position of the gingival tissue.
The last step in the periodontal evaluation is the measurement of clinical parameters, which include periodontal probing depth, gingival recession, clinical attachment loss, and bleeding on probing.
Once the diagnosis of periodontitis has been made, it’s important to get the staging of the disease to classify the severity and grading of the disease to look at the speed of progression and response to treatment.
Finally, we can order additional tests like genetic studies and bacterial cultures to help guide management.