Perio Exam and Assessment

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Perio Assessment: Assessing for...

The presence or absence of disease
Amount of biofilm present
Gingival description
Calculus deposits
Probing depths
Bleeding upon probing
Presence of recession
Width of attached gingiva
Clinical attachment loss/level
Presence of mobility
Furcation involvement

Other Factors affecting perio health

Poor restorative margins
Malposed and crowded teeth
Missing teeth
Oral habits
Systemic factors

Components of the Perio Assessment

Missing teeth, malposed teeth
Recession
Pocket depths and bleeding points
Furcation involvement
Attrition
Mobility
CAL (clinical attachment level)
Width of attached gingiva (WAG)

How are missing teeth recorded on chart?

With a large X through all aspects of the tooth

How are malposed teeth recorded on the chart?

With an arrow showing the direction of the rotation or a note explaining which teeth are crowded and the severity

Some reasons to have current radiographs?

to check for missing teeth, retained root tips, impacted teeth, retained deciduous teeth, supernumerary teeth

How are pocke depths charted?

In black ink

How are bleeding points charted?

As red dots next to the pocket depth number in the box

How is recession charted?

As a red line across the root surface with the number of millimeters of recession to the right of the red line (dont have to write mm, just #)

How is attrition charted?

by drawing two horizontal red lines across the incisal edges of the anterior teeth and wear facets on post. teeth are documented in the comment area

What is horizontal mobility?

the ability to move the tooth in a facial-lingual direction in its socket

What is vertical mobility?

ability to depress the tooth in its socket

Mobility Classifications (1-3)

Class 1: Slight mobility, up to 1 mm of horizontal displacement in a facial-lingual direction
Class 2: Moderate mobility, greater than 1 mm of horizontal displacement in a facial-lingual direction
Class 3 :Severe mobility, greater than 1 mm of displacement in a facial-lingual direction combined with vertical displacement (tooth depressible in the socket)

How do you determine the total width of attached gingiva?

By measuring from the gingival margin to the mucogingival junction on the buccal/facial aspect of the tooth. You then measure the pocket depth on the straight buccal. Subtract the probing depth from the total width to get the width of attached gingiva.

Adequate width of attached gingiva is...

considered 2 mm or more of attached gingiva

Minimal width of attached gingiva is...

anything less than 2mm (indicated by a red, zig-zag line on the root of the tooth)

Clinical Attachement Level (CAL)

Refers to the estimated position of the structures that support the tooth as measured with a periodontal probe. The CAL provides an estimate of a tooth's stability and the loss of bone support. Can be used synonymously with clinical attachment loss or the extent of periodontal support that has been destroyed around a tooth.

How to calculate the CAL

Calculated from the CEJ (which is a fixed point that doesn't change) Because the bone level in health is approximately 2mm apical to the CEJ, the CAL provides a reliable indication of the extent of bone support for a tooth.

CAL with recession

calculate by adding the probing depth to the gingival margin level

CAL without recession

When the gingival margin is at the CEJ, no calculations are needed because the probing depth and the clinical attachment level are equal

CAL with gingival margin covering the CEJ

Subtract the gingival margin level from the probing depth when the gingival margin is coronal to the CEJ

Perio Charting Sequence

Determined by the system your office is using
Computer assisted charting sequence may be different from manual charting
-Some computer systems are voice activated
-Some systems allow you to change the sequence
-Some systems have left and right-handed sequences

Class I Furcation

Furcation can be felt with probe tip, however the probe cannot enter the furcation area, symbol ^ (upside down V)-green

Class II Furcation

The probe can partially enter the furcation, extending approx 1/3 of the width of the tooth but cannot pass completely through, symbol empty triangle-green

Class III Furcation

Man. Molars= the probe passes completely through furcation netween mesial and distal roots
Max Molars= probe passes between the mesiobuccal and distobuccal roots and touches the palatal root, symbol colored in triangle-green

Class IV Furcation

Same as class III involvement except the entrance to furcation can be clinically seen due to tissue recession, symbol colored in diamond-green

Charting other localized factors

Most other local factors should be written up in "comments" area on the perio charting sheet such as:
-Food impaction written in comments area with tooth numbers and Hx information from the patient
-If the food impaction involves an open contact, you can chart the area with two small vertical lines between the teeth involved
-Overhanging margins will be covered in the Dental Charting lecture
-Clenching/grinding habit written in comments area with Hx

Reasons for Classifying health and disease?

-To establish baseline data
-System sets a standard for recording the extent and severity of inflammation and destruction of supporting perio structures
-Data to create plan for DH therapy
-Data for Comparison at maintenance visits

What questions can you answer for Data for comparison at maintenance visits?

Has therapy been successful?
Is the patient's home care effort successful?
What else can be done to promote optimum health in a compromised situation?
Additional DH therapy?
Other oral hygiene aids?
Referral to a periodontist for surgery?

3 major categories of AAP classification?

Gingivitis and Periodontitis

AAP class system takes into consideration what factors when id perio diseases?

Age of onset
Clinical appearance
Rate of disease progression
Pathogenic microbial flora
Systemic influences

ADA Classification

Developed by the American Dental Association
Primarily based on the severity of attachment loss.
Clinician uses the clinical and radiographic data gathered and classifies the patient into one of the four Case Types.
These Case Types are commonly required for insurance billing. Also provide guidelines for treatment recommendations.

Classification of Case Types

Case Type 0—Healthy gingiva
Case Type I—Gingival Disease
Case Type II—Early Periodontitis
Case Type III—Moderate Periodontitis
Case Type IV—Advanced Periodontitis
Case Type V—Refractory Periodontitis

Case Type 0

Generalized healthy gingiva
May have isolated areas of BOP (bleeding upon probing)
No bone loss
1-3 mm pocket depth with isolated 4 mm.

Case Type 1-Gingivitis

Generally inflamed as characterized by slight to moderate changes in color, contour, and consistency
Radiographic findings: No evidence of bone loss, Crestal lamina dura is present, Alveolar bone level is within 1-2 mm of the CEJ area
Bleeding may or may not be present
Pocket depths 2-4 mm
Pseudopockets may be present from 3-6 mm

Case II- Early Periodontitis

Generalized slight to moderate inflammation characterized by changes in color, contour, and consistency progressing into deeper periodontal structures.
Bone loss evident from localized areas of recession
Pocket depths 3-5 mm
Possible Class I furcation invasion areas
Radiographic findings: Horizontal type bone loss, most commonly, Slight loss of interdental septum,Alveolar bone level is 3-4 mm from CEJ area

Class III- Moderate Periodontitis

Advanced stages of inflammation characterized by increased destruction of periodontal structures and generalized bleeding upon probing.
Pocket depths from 4-6 mm
Class I and II furcation involvement may be evident with mobility
Radiographic findings: Horizontal or vertical bone loss may be present, Alveolar bone level is 4-6 mm from CEJ area, Class I and II furcations,Loss of 1/3 of supporting alveolar bone

Class IV- Advanced Periodontitis

Further progression of inflammation with major loss of alveolar bone support.
Bleeding upon probing and pocket depths 4-7+ mm
Radiographic findings: Horizontal and vertical bone loss, Alveolar bone level is 6 mm or more from CEJ area, Radiographic furcations evident, Loss of over 1/3 of supporting alveolar bone

Class V-Refractory Periodontitis

Condition that describes continued attachment loss in spite of "well-executed" periodontal therapy and proper oral hygiene.
Other factors may include:
Extent of disease prior to therapy, Type of therapy provided (surgical vs. non-surgical), Tooth type and furcation involvement, Species and strains of microflora, Degree of host response

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