Periodontal Disease Recognition:
A Review course for Dental Hygienists

Ara Aguiar, RDH, MBA

At the end of this lecture, you will be asked if you would like to take this course for continuing education units.
California Continuing Education Credits: 2 units

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Periodontal Disease Recognition
Classifications and Categories of Periodontal Disease
Completion of Periodontal Exam

As part of the dental team, the dental hygienist plays an active role in the recognition and treatment of periodontal disease. Providing a thorough assessment and complete periodontal examination will ensure that periodontal disease is detected, documented and treated. This tutorial reviews the periodontal data necessary to achieve optimal periodontal health for your patients.

Objectives

Medical History

A thorough medical history will identify systemic conditions requiring modifications prior to dental treatment. For example: Prophylactic antibiotics for a history of heart murmurs, artificial joint replacements, or adjustments in intake of medications. The medical history may also identify other factors that may contribute to the progression of periodontal disease or hinder the patient's healing response. For example: Calcium Channel-Blockers, Dilantin and Cyclosporin which have been identified as medications that could contribute to gingival overgrowth. Another example are patients with a history of Diabetes or Hemophilia which may have complications with healing or infections. In patients with an extensive medical history, it is often helpful to consult with the patient's medical doctor prior to initating treatment.

Dental History

A comprehensive dental history of previous periodontal procedures such as, osseous surgeries or grafts will help the clinician to compare and assess the patient's current clinical and radiographic findings. It also provides the background to develop an individualized dental hygiene treatment plan.

Recognition of the Patient's Periodontal Status
A thorough periodontal examination consists of the following clinical and radiographic data.

Full mouth periodontal probings

Attaining full mouth probings on every patient will provide the following information.

Baseline Data
The baseline data can be used to compare future changes in the patient's periodontal status. It is recommended that a full mouth probing be completed at the initial new patient appointment and on a regular basis on patients of record. In the "Risk Management Series: Diagnosing and Managing the Periodontal Patient" published by the American Dental Association it is recommended that "a periodontal evaluation for every patient at least annually, preferably biannually, to reduce tooth loss and prevent malpractice claims". Patients with a previous history of periodontal problems or that show clinical signs and symptoms of active disease, it is recommended that probings be completed every 3 months.

Pocket Depth and Attachment Level
This diagram illustrates how to access severity of attachment loss. Two clinical measurements are necessary, recession and pocket depth. Recession is the measurement from the CEJ to the gingival margin. Pocket depth is the measurement from the gingival margin to the bottom of the sulcus/pocket. The total number of millimeters from the CEJ to the epithelial attachment or bottom of the sulcus/pocket (the sum of pocket depth and recession) represents the severity of attachment loss.

Bleeding Upon Probing
Bleeding points during the probing procedure identifies areas of inflammation that can be representative of disease activity or progression of periodontal disease.

Documentation
Documentation of periodontal findings provide a legal record that a thorough assessment was done on a routine basis for the patients in the practice. In addition, insurance companies now require that a record of full mouth probings be sent when billing most periodontal procedures. Today, it is common practice to "alternate" the dental hygiene visit between general and periodontal practices. Sharing clinical findings will optimize communication between clinicians responsible for the patient's periodontal health.

Education
Often times the periodontal probings can be used as an educational tool to discuss the present status of periodontal disease with patients. Involving the patient by showing them the recorded probings can be helpful in attaining treatment acceptance of periodontal procedures.


Gingival Recession

Is the measurement from the CEJ to the marginal gingiva. Documentation of recession is necessary in order to determine severity of attachment loss and monitor changes in the movement of the marginal gingiva in either an apical or coronal direction due to inflammation or gingival overgrowth.

Furcations

Furcations are recorded depending on the severity of attachment loss, graded from early to advanced involvement.

Grade I

The level of bone loss allows for the insertion of the periodontal probe into the concavity of the root trunk. This slide illustrates a Class I furcation invasion. A Nabers probe was used to assess the furcation.
Grade II

The level of bone loss allows for the insertion of a periodontal probe into the furcation area between the roots. The slide illustrates a Class II furcation invasion.
Grade III

The level of bone loss allows for "through and through" access of the furcation area. Buccal to lingual on lower molars. Buccal to mesio-palatal and disto-palatal on upper molars. This slide illustrates a Class III furcation invasion.


Evaluation of Tooth Mobility


Tooth mobility may be present due to hyperfunction or loss of attachment. This slides illustrates how to assess for tooth mobility by using the index finger and the handle of a probe.

Class I
0.5 to 1.0 mm facial-lingual tooth movement

Class II
1 mm to 2 mm facial-lingual tooth movement

Class III
Over 2 mm facial-lingual tooth movement and apical coronal depressibility

Identification of areas with mucogingival involvement

Can be classified as areas with less than 1 mm of attached gingiva.
This slide illustrates a mucogingival involvement area with no attached gingiva.

Interpretation of Radiographic Findings

The following radiographic data is used to supplement the clinical findings. Any new radiographic findings are compared to the clinical findings and documented in the patient's chart.

Types of Bone Loss
Are identified as areas of horizontal or vertical bone loss. It is important to note that treatment modalities and treatment outcomes may differ between horizontal and vertical bone loss.


This radiograph illustrates horizontal bone loss in the posterior sextant. The crestal bone margin is horizontal and parallel to CEJ. The bottom of pocket is coronal to the adjacent alveolar bone. Note the "crater-like" interproximal defect common to the mandibular arch.

This radiograph illustrates vertical or angular bone loss.
The crestal bone margin is not parallel to the cementoenamel junction
Bottom of pocket is apical to the adjacent alveolar bone.

Level of bone loss
Comparing the radiographs to the dental probings and recession areas will assist in concluding the level of attachment loss.

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