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Learning Outcomes

You should be able to:

• Discuss the scores of the BPE and the related indication for

treatment

•Recognise when to carry out a full-mouth periodontalexamination based on the BPE scores

• Describe step-by-step how to complete a full-mouth

periodontal examination

• Correctly identify anatomical references to measure probing

depth, recession and clinical attachment loss

• Describe the classification for tooth mobility and furcation

and how to record this in a full-mouth periodontal chart

Cont…

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2

nd

Part • Discuss the role of a full-mouth periodontal chart to help

determine the correct diagnosis in conjunction with the

patient’s history, risk factors for periodontal disease and

radiograph

• Discuss the importance of monitoring plaque and

bleeding scores as part of the periodontal treatment

• Discuss the aims of a review session and making

arrangements for appropriate recall time

(WILL BE DELIVERED LATER THIS YEAR)

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RECAP from Transition 4:

History and Examination

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The Periodontal Patient 

• HISTORY TAKING

• COMPLAINT OF

• HISTORY OF PRESENTCOMPLAINT

• MEDICAL HISTORY

• SOCIAL HISTORY

• PAST DENTAL HISTORY

• EXAMINATION

• EXTRAORAL EXAM

• INTRAORAL EXAM

• Soft tissues: description

• Hard tissues: charting/occlusion

• Periodontal tissues: gingival

characteristics, OH, BPE

DIFERENTIAL DIAGNOSIS

SPECIAL INVESTIGATIONS:Radiographs, full mouthperiodontal chart, vitalitytest and palpation (ENDO),impressions (PROS), baselineplaque and bleeding scores

DEFINITIVE DIAGNOSIS

PROGNOSIS

TREATMENT PLANNING

(Em.; Stabiliz.+Review; Rest.)

FOLLOW-UP (Maintenance Phase)

• RECALL

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H&E:

 Assess Periodontal Health

and 

Oral Hygiene Behavior 

Aetiology of Periodontal Disease: Infection (plaque)

Pathophysiology: Inflammatory/Immune Reaction

• by taking relevant history,

• performing clinical examination

• results from special test (probing, mobility, radiographs, etc)

• recording and monitoring dental plaque

Periodontal Diagnosis Periodontal Treatment Review

Periodontal Maintenance RECALL

D&T:

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Most Common Periodontal C/O•C/O + HPC

Check- up (Perio Disease no signs or symptoms)

Bleeding gums

- Is it bleeding on brushing? Is it spontaneous?

- When it started?

- Do you feel any mobility? Is it increasing?- Do you notice any bad breath or bad taste?

- Did you notice that your gums are pulled away?

Gum recession

- When did it started?

- Do you have any sensitivity?

- How often do you brush your teeth?

- Review brushing technique

- Did you have “orthodontic”  treatment before? (braces)

- Any bleeding on brushing/mobility?

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• Mobile teeth

• When this was noticed first?

• Is it increasing?

• Any specific tooth, more than one? Which ones?

• Change in position?

• Any bad breath or bad taste?

• Pain?

•

Any diagnostic of periodontal disease?• Any previous treatment? By who? When? What treatment?

• Does this prevent you from eating?

• Patient’s needs and desires for treatment

• Expectations for treatment outcome – aesthetics may be compromised

• Patient’s demands may not be congruent

• COMMUNICATION is important

• Specialist referral?

Discuss Patient’s Expectations

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Medical History and Perio

• Some systemic diseases, conditions or behavioural factors may play arole in the cause of the disease

• The presence of conditions may require special precautions ormodification of treatment

• Oral infections may have an influence on occurrence and severity ofsystemic diseases

• Check for:• Bleeding disorders: Anaemia

• Liver disease. eg. cirrhosis, impaired coagulation

• Diabetes. Increased risk factor for PD

• Cardiovascular diseases, HBP… medication?

• Drug-induced gingival hyperplasia:• calcium channel blockers: amlodipine, nifedipine

• Anticonvulsants (epilepsy): phenytoin

• Immunosuppressant: cyclosporine

• Hormone-related conditions and Pregnancy

•

Allergies

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Social History and Perio•

Priorities and attitude to dental care• Availability for treatment

• Problems attending many appointments, lengthyappointments

SMOKING

• Cigarette smoking is the 2nd most important RiskFactor in periodontal disease.

•

Exposure time and quantity• When, How many, How long?

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Family History and Perio

• Family history of periodontitis (Aggressive

Periodontitis)

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Past Dental History and Perio

• Signs and symptoms of periodontitis noted by the patient:• Tooth migration

• Increasing mobility of the teeth

• Bleeding gums

• Food impaction• Difficulties in chewing

• Frequency and duration of daily toothbrushing

• Knowledge about interdental cleansing and use of

mouthwash• Previous periodontal treatment and maintenance

• Use of prosthesis or need for one

• Previous or current orthodontic treatment

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INTRAORAL

EXAMINATION 

What is periodontalhealth?

HealthDisease

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Healthy Gingival Tissues

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Describe gingiva

Systematic approach

1. Colour

2. Size

3. Shape

4. Contour

5. Consistency

6. Surface texture

7. Position

* Transition 4_ Tutorial 1

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Localized, diffuse, intensely red area facial of UR2 and dark-

pink marginal changes in remaining anterior teeth

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Generalized diffuse gingivitis involves the

marginal, papillary, and attached gingivae

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Discoloration of the gingiva caused by embedded

metal particles (amalgam)

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Gingival inflammation and enlargement associated with

orthodontic appliance and poor oral hygiene

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Gingival enlargement associated with phenytoin therapy. Note the

prominent papillary lesions and the firm, nodular surface

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Twelve-year-old female with a primary medical diagnosis of

leukaemia that exhibits swollen/spongy gingiva

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Clinical image of plaque-related moderate chronic

periodontitis with 3 to 4 mm clinical attachment loss in

53-year-old male smoker

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Gingivitis

vs

Periodontitis

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Screening for Periodontal

Disease

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BPE

Score Disease Treatment

0 No disease No need

1 Bleeding OHI

2 Plaque retentive OHI, remove

factors

3 Pocket >3.5 OHI, RSD

4 Pocket >5.5 OHI, RSD,

assess need

complex tx,

referral?

* Furcation = 4

WHEN DO WE NEED TO COMPLETE A 6PPC? 

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BPE test in LAB!

(next week)

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Periodontal Attachment System

in Health

GINGIVA

PERIODONTALLIGAMENT

ALVEOLAR

BONE

CEMENTUM

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Position of the Gingival Margin

• In periodontitis, the

gingival margin may

remain near the CEJ.

• This creates a deep

periodontal pocket.

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Recession of Gingival Margin

• Gingival margin has

receded and tooth roots

are visible

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The gingiva can mask bone loss

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What to register in the 6PPC?

• Teeth not present

• Probing depth at 6 sites/tooth

• Recession

*Clinical Attachment Loss• Mobility

• Furcation

• Bleeding on probing (6 sites)

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Measurements Recorded

• Measurements are

recorded for six specificsites on each tooth.

FOR PROBING DEPTH

FOR RECESION

FOR BLEEDING ON PROBING

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Record the Deepest

Measurement 

• In this example, the

deepest reading would berecorded for the facial

reading (yellow shade in

previous slide).

• That reading is the one

taken at point C.

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Limitations of Measurements

Various factors can affect accuracy and

repeatability of measurements:

 – Position of gingival margin

 – Interference from calculus deposits,overhanging restorations

 – Amount of pressure applied

 –

Misread probe calibrations – Probe position in healthy and diseased

pockets

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CONCEPT 2: Recession

Measurement of the Gingival margin

(GM-CEJ)

Recession Recession ?

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1. Margin Slightly Coronal to CEJ

• The natural position of the

gingival margin in health

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2. Margin Apical to CEJ

• Seen on these three

anterior teeth

• Termed “recession”

• Common in periodontitis

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3. Margin Covers CEJ

• The gingival margin

significantly covers CEJ

•

Commonly seen ingingivitis caused by

medications (Gingival

hyperplasia)

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Recording Positive(+) or

Negative (-)• When recording recession of the gingival margin, think:

“How much gingival tissue would be added (+) to return

margin to normal position?”

• When recording gingival margin that covers CEJ, think:

“How much gingival tissue would be taken away (-) to return

margin to normal position?”

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CONCEPT 3: Clinical Attachment Loss

Measurement CAL = base pocket-CEJ

OR CAL= Probing depth + Recession

How

much

boneloss?

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• What is the probing

depth?

• What is the GM-CEJ

distance?

• What is the CAL?

Tooth B

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Tooth C

• What is the probing

depth?

• What is the GM-CEJ

distance?

• What is the CAL?

Bl di Bleeding

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Bleeding

score

• Bleeding score is a measurement

of inflammation at gingival margin

• It relates to the oral hygiene

status of the patient

• Ideal for OH control and

monitoring in long-term

Bleeding

on probingvs.

• Recorded as part of the 6PPC during probing

• Measure presence of inflammatory lesions located

at the base of the periodontal pocket

• Insertion of probe elicits bleeding if gingiva is

inflamed and the pocket epithelium is atrophic

or ulcerated.

• Red dot on top of PD measurement (at 6 sites/tooth)

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Mobility - technique

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Classification of Mobility

Class 1 Slight mobility, up to 1 mm of horizontal

displacement in a facial-lingual direction

Class 2 Greater than 1 mm but less than 2mm ofhorizontal displacement in a facial-lingual

direction

Class 3 Greater than 2 mm of horizontal displacementin a facial-lingual direction or vertical mobility

F i

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Furcation

Furcation Anatomy

Furcation entrance and where

to measure from

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Nabers Probe

Rating furcation involvement

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Rating furcation involvement

3

3

OBS: Consider that 1st clear band

of Naber’s probe measures 3mm

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Full-Mouth Periodontal

Examination (6PPC)

Step-by-step

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1

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2

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34

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5

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6

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7

8

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8

Highlight or circle the POCKETS, or use a colour code to help understanding the problem

In the example: Mild= yellow (4mm) Moderate = pink (5-6mm) Severe= orange (7+)

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Name of the patient

date

date

date

123 456 789

date

date

date

123 123 123

No mobility [or] 1 2

v

. . . . . .

1

2

3

4

5

6

7

Highlight the

pockets

PRACTICAL

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PRACTICAL

FMPC - Lab1/Clinic1

Learning OutcomesBy the end of the session you should be able to:

• Demonstrate the correct use of a Williams probe to measure

the probing depth at 6 sites around each tooth

• Identify factors that can affect the accuracy of periodontal

probing

• Demonstrate the technique for assessing tooth mobility and

furcation

• Demonstrate how to describe and interpret the information

collected through a full-mouth periodontal examination

• Perform a full-mouth periodontal examination in your clinical

partner

Bring your handbook! 

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g y

Lab 1: Full-Mouth Periodontal Chart • WHEN: 8th and 12th December

MON 1-3pm/MON 3-5pm/FRI 9-11am/FRI 11-1pm

• WHERE: LABORATORY 3rd Floor

• 2 hour session/ 2 groups/ 2 tutors

Individually:• Sign attendance, log-in to QMplus tutorial, prepare your bay (15 min)• BPE Exam (10 minutes)

• Self-Assessment Form: Full-Mouth Periodontal Chart (60min)

• BPE

• Williams probe

• Full-Mouth Periodontal Chart

• Clinical Attachment Loss

• Tooth mobility

• Furcation Involvement

• Clear-up your bays (10min)

•On-line Feedback

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Please

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Please

remember