c hapter 8 clinical assessment copyright © 2014, 2007, 2001, 1996 by saunders, an imprint of...

I NTRODUCTION Assessment is the first stage in the dental hygiene process of patient care. It provides the foundation for the diagnosis, planning, implementation, and evaluation of dental and dental hygiene care. Documentation of the gathered information is critical to have as a reference tool, a historical record, and a patient educational resource. It also serves an important medicolegal function as a record of care. 2 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

I NTRODUCTION (C ONT.) The assessment of a patients periodontal status includes the: Chief complaint Medical and dental histories Clinical examination Radiographic examination 3 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ATIENT H ISTORY Medical History Is obtained at the initial appointment and is reviewed at each subsequent visit. Aids the clinician in: 1. Evaluating oral manifestations of systemic disease 2. Detecting systemic conditions that may affect the periodontal tissue response 3. Detecting systemic and infectious conditions that require special precautions and modifications in the treatment procedures 4 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ATIENT H ISTORY (C ONT.) Medical History (cont.) The medical history questionnaire should be orally reviewed with the patient. No question should remain unanswered. Consultation with other treating health care providers may be necessary. The medical history should be dated and signed by both the patient and the dental hygienist. 5 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ATIENT H ISTORY (C ONT.) Medical History (cont.) Patient vital signs should be taken and documented in the medical history. These include blood pressure, pulse, and respiration rate. Vital signs should be noted at the initial interview and all subsequent medical history updates. 6 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ATIENT H ISTORY (C ONT.) Dental Health History A patient should be asked to identify his or her chief complaint or reason for seeking oral health care. If a patient reports dental problems, further questioning should include: Specific location Stimulus that elicits pain Duration of stimulation Frequency of occurrence Date of the initial problem Changes in the problem since the initial identification 7 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ATIENT H ISTORY (C ONT.) Dental Health History (cont.) A dental history should also include information about the patients previous dental experiences, current oral hygiene practices, and attitudes toward dentistry. Information about the patients habits, such as tobacco use, alcohol use, and/or possible recreational drug use, are important elements of the assessment. 8 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ATIENT E DUCATION The prevention and educational strategies for each patient are aimed at the factors that are identified during the clinical assessment. The focus is generally on plaque biofilm removal, periodontal disease, dental caries prevention, diet modifications, and the use of fluorides. Documenting in the patient record the oral hygiene aids that have been prescribed, dispensed, and introduced to the patient is important. 9 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION Extraoral and Intraoral Assessment The head, neck, and oral cavity should be examined using visual and tactile techniques. Findings from this assessment are used to develop the dental and dental hygiene treatment plan and the patient education plan. The extraoral and intraoral assessment may also identify a need for medical consultation and/or referral to a dental specialty. 10 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) Oral Mucosa Assessment Three types of oral mucosa line the oral cavity: Masticatory Specialized Lining 11 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) Oral Mucosa Assessment (cont.) The following figure demonstrates the anatomy of the normal gingiva adjacent to a tooth in diagrammatic form. 12 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) Oral Mucosa Assessment (cont.) The amount of attached gingiva is noted. Attached gingiva extends from the free gingival groove to the movable alveolar mucosa. The intersection of the two is called the mucogingival junction. 13 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) Oral Mucosa Assessment (cont.) The mucogingival junction is usually revealed as a slightly scalloped line as demonstrated in the following figure.. 14 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) Oral Mucosa Assessment (cont.) To determine the amount of attached gingiva on the buccal aspect of the mandible and maxilla: Stretch the lip and cheek to demarcate the mucogingival line. Measure the distance from the gingival margin to the mucogingival junction. Subtract the pocket depth. 15 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) On the lingual aspect of the mandible, the attached gingiva extends from the free gingival groove to the mucogingival junction. It is continuous with the lining of the floor of the mouth. On the palatal aspect of the maxilla, the attached gingiva is continuous with the masticatory palatal mucosa. 16 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) The interdental papilla is the tissue between two adjacent teeth. It consists of a facial or buccal papilla, a lingual papilla, and a col. The col is the depression connecting the facial or buccal papilla and the lingual papilla. It is usually nonkeratinized and conforms to the interproximal contact area. It is often absent in areas in which teeth are not in contact. 17 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) The following four categories determine the health status of the gingiva: Color Contour Consistency Texture 19 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) Color The color of normal marginal and attached gingiva is pale coral pink. Color can vary as a result of individual skin pigmentation, degree of vascularity, and epithelial keratinization. Bright red gingival tissues indicate acute inflammation. Dark red to cyanotic gingival tissues indicate chronic inflammation. 20 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) Contour The contour of healthy marginal gingiva is uniformly scalloped. Healthy interdental papillae appear as pointed, knifelike tissues that fill embrasure spaces between the teeth. Inflamed gingival margins appear swollen, rounded, or shiny, and the scalloped appearance may be lost. 21 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) Contour (cont.) When the papillae are inflamed, their appearance may be flattened, blunted, bulbous, cratered, or hyperplastic. Festoons are inner tubelike swellings at the gingival margin. Clefts, such as a Stillman cleft, appear as slitlike depressions on the facial or lingual gingival margins. 22 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) Consistency The consistency of marginal and interdental gingiva should be firm when palpated with the side of a blunt instrument, such as a periodontal probe. In the presence of inflammation, the gingiva may be soft and spongy, swollen, shiny, and easily deflected away from the tooth. 23 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) Consistency (cont.) In health, attached gingiva has a stippled, orange peellike texture. When inflamed, the gingiva loses its stippled texture and appears rolled, shiny, and smooth. In the case of extremely fibrotic tissue, the stippling may still be apparent, even in the presence of inflammation. 24 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) Alveolar Mucosa Alveolar mucosa is loosely attached, movable tissue that is not keratinized. It is darker than the attached gingiva. The alveolar mucosa begins at the mucogingival junction and is continuous with the lining mucosa of the oral cavity. 25 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) Frenums Frenum attachments are folds of mucosal tissues, often including muscle fibers that join the movable mucosa to attached or specialized mucosa. The lingual frenum attachment is located on the underside of the tongue. Maxillary and mandibular buccal frenum attachments are located at the cuspids and premolars. 26 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) Frenums (cont.) The maxillary and mandibular anterior frenum attachments are located at the midlines of the maxillary and mandibular central incisors as demonstrated in the following figure. 27 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C LINICAL E XAMINATION (C ONT.) Oral hygiene assessment includes a clinical evaluation of the presence of plaque biofilm, calculus, and stain. The data collected help the dental hygienist draw connections to develop a dental hygiene treatment plan, design patient education strategies, and evaluate the outcome of oral hygiene instruction. 30 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P LAQUE B IOFILM Identifying and documenting the location of plaque biofilm on the teeth can be used to educate patients on their specific oral hygiene prevention needs and provide a record over time. Plaque biofilm can be stained with red-disclosing solution to help patients see it, or plaque biofilm can be shown to the patient when removed with an explorer or other instrument. 31 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P LAQUE B IOFILM (C ONT.) The OLeary plaque control record provides a method of recording the presence of plaque biofilm at the gingival third of the buccal, lingual, mesial, and distal surfaces of each tooth. The OLeary record quantifies the percentage of total tooth surfaces with plaque biofilm. For example: 20 surfaces with recorded plaque biofilm 40 total surfaces = 50% The OLeary plaque control method is useful in research protocols requiring standardized recording of patient data. 32 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P LAQUE B IOFILM (C ONT.) In the clinical setting, the amount of plaque biofilm is usually described as light, moderate, or heavy. Location is also notedgeneralized or localized. If localized, then additional information should be noted such as anterior, posterior, buccal, lingual, interproximal, and cervical or marginal. This documentation can be used to compare and evaluate the success of the plaque biofilm prevention program. 33 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C ALCULUS Supragingival calculus can be directly observed. Deposits are more easily observed when dried with air. Subgingival calculus of each tooth surface is detected with an explorer. 34 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C ALCULUS (C ONT.) Radiographic images may show heavy interproximal calculus deposits as illustrated in the following figure. 36 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C ALCULUS (C ONT.) Calculus is usually present in greater amounts than what is revealed on two-dimensional images. A combination of tactile, radiographic, and visual detection of subgingival calculus remains the standard for the assessment of calculus. Detection methods may be enhanced through the use of fiberoptic endoscopy, spectro-optical scanning, autofluorescence, ultrasound, and combined laser-autofluorescence technologies. 37 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

D ENTAL AND O RAL T ISSUE S TAIN Pigmented deposits on the tooth surface are called extrinsic stains. They are primarily esthetic problems that result from the pigmentation of ordinarily colorless acquired pellicle and dental plaque biofilm by chromogenic bacteria, foods, and chemicals. These removable stains vary in color, composition, and firmness of adherence to the tooth surface. 38 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

D ENTAL AND O RAL T ISSUE S TAIN (C ONT.) Intrinsic stains occur within the tooth structure and cannot be mechanically removed by scaling or polishing. A common cause of intrinsic staining is discoloration that is the result of pre-eruption and post-eruption drug interactions (e.g., tetracycline, minocycline). 39 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

E XTRINSIC S TAINS Brown Stain Brown stain is a thin, translucent, acquired, bacteria-free pigmented pellicle. It is the most commonly occurring stain and appears at varying intensities throughout the dentition. Brown staining is often caused by tannin, which has a denaturating effect on pellicle proteins, and is found in coffee, tea, fruits, or red wine. 40 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

E XTRINSIC S TAINS (C ONT.) Brown Stain (cont.) Tobacco produces tenacious dark brown or black surface deposits and brown discoloration of tooth structure. Chlorhexidine, a general antiseptic, imparts a brown staining on the cervical and interproximal regions of the teeth, on restorations, in plaque biofilm, and on the surface of the tongue. Stannous fluoride imparts a yellow-brown or golden discoloration of the tongue and teeth. 41 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

E XTRINSIC S TAINS (C ONT.) Black Stain Black stain usually occurs as thin lines on the facial and lingual surfaces of teeth near the gingival margin. Chromogenic bacteria, which may be the cause of the black pigmentation, dominates the microbiota of black stain. Another theory suggests that an insoluble ferric sulfide produced as a result of an interaction of hydrogen sulfideproducing bacteria and iron from the saliva and gingival fluid is the cause of black stain. 43 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

E XTRINSIC S TAINS (C ONT.) Green Stain Green stain is a green-yellow stain, sometimes of considerable thickness. It may be stained remnants of the enamel cuticle. The discoloration has also been attributed to fluorescent bacteria and fungi, such as Penicillium and Aspergillus. Green stain usually occurs on the gingival half of the facial surfaces of anterior teeth. 44 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

E XTRINSIC S TAINS (C ONT.) Orange Stain Orange stain is less common than green or brown stain. It may occur on both the facial and lingual surfaces of anterior teeth. Serratia marcescens and Flavobacterium lutescens have been suggested as the responsible chromogenic organisms. 45 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P RE -E RUPTION I NTRINSIC S TAINS Fluorosis Excessive ingestion of fluoride can cause hypomineralization of enamel during development known as fluorosis. The esthetic appearance is discolored and mottled. Mild fluorosis appears as white flecks, primarily on cusp tips and facial surfaces of permanent dentition. More severe forms of fluorosis appear as white opaque areas or darkly stained with pitted enamel. 46 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P RE -E RUPTION I NTRINSIC S TAINS (C ONT.) Tetracycline Stains Tetracycline can cause tooth discoloration when used during tooth development. Appearance may range from yellow to gray- brown in color. Tetracycline staining cannot be removed. 47 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P RE -E RUPTION I NTRINSIC S TAINS (C ONT.) Tetracycline discoloration takes on a banded appearance in the section of the tooth developing at the time of exposure, as demonstrated in the following figure. 48 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P RE -E RUPTION I NTRINSIC S TAINS (C ONT.) Other Intrinsic Stains Tooth discoloration may also occur as a result of: Metabolic factors (e.g., hypothyroidism) Inherited factors (e.g., amelogenesis imperfecta and dentinogenesis imperfecta) Systemic disorders (e.g., cystic fibrosis) Environmental factors (e.g., trauma) 49 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P OST -E RUPTION I NTRINSIC S TAINING Minocycline Stains Minocycline, a commonly used medication, has been shown to cause intrinsic dental and oral tissue discoloration. The onset of discoloration can occur within 1 month or many years after the initiation of treatment. The discoloration ranges in color from green-gray to blue-gray. 50 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P OST -E RUPTION I NTRINSIC S TAINING (C ONT.) Other Intrinsic Discoloration Pink tooth is observed in cases of internal resorption and invasive cervical resorption as a result of inflamed pulp tissue and inflamed periodontal granulation tissue. 52 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ERIODONTAL A SSESSMENT Periodontal assessment includes the evaluation of: Periodontal probe depths Clinical attachment levels Gingival bleeding Suppuration Furcations Mobility Pathologic tooth migration 53 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ROBING M EASUREMENTS Periodontal probing provides a numerical assessment of the apical extent of the epithelial attachment in relation to the gingival margin and the cementoenamel junction. Probing measurements are used to evaluate periodontal disease status, support treatment planning decisions, design individualized prevention plans, and determine the success of treatment. 54 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ROBING M EASUREMENTS (C ONT.) A periodontal probe is used to obtain two types of probing measurements: 1. The distance between the gingival margin and the base of the gingival sulcus. This measurement is known as the periodontal pocket depth, the probing depth, or, as in the case of periodontal health, the gingival sulcus depth. Measurements should be taken at six sites on each tooth: distobuccal, buccal, mesiobuccal, distolingual, lingual, and mesiolingual. 55 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ROBING M EASUREMENTS (C ONT.) A periodontal probe is used to obtain two types of probing measurements: (cont.) 2. Clinical attachment loss is the second probing measurement. The clinical attachment is the distance between the cementoenamel junction and the most apical extent of the epithelial attachment. When the cementoenamel junction is visible, adding the periodontal pocket depth to the gingival recession measurement determines the clinical attachment. 57 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ROBING M EASUREMENTS (C ONT.) 2. Clinical attachment loss is the second probing measurement. (cont.) Gingival recession is the distance between the cementoenamel junction and the gingival margin. When the gingival margin is coronal to the cementoenamel junction, the distance between the gingival margin and the cementoenamel junction is subtracted from the periodontal pocket depth to calculate the clinical attachment loss. 58 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ROBING M EASUREMENTS (C ONT.) The significance of clinical attachment loss, along with probing depth, is demonstrated in the following figure. 59 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ROBING M EASUREMENTS (C ONT.) Clinical Attachment Loss Clinical attachment loss provides the most accurate and reliable means of assessing the progression and remission of periodontal disease. 60 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ROBING M EASUREMENTS (C ONT.) The following figure demonstrates the difference between clinical attachment loss and periodontal probing depth. 61 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ROBING M EASUREMENTS (C ONT.) The following figure demonstrates the difference between clinical attachment loss and periodontal probing depth. 62 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ROBING M EASUREMENTS (C ONT.) Probing depths are affected by the clinicians insertion force, probes tip size, angulation, and patients gingival inflammation status. The probe tip easily penetrates inflamed epithelial attachment and typically results in measurements that are generally 1 mm deeper than the histologic depth of the pocket, even with the most careful technique. 63 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ROBING M EASUREMENTS (C ONT.) Bleeding Bleeding on probing is not an absolute predictor of active disease. However, persistent bleeding on probing over time is of particular importance. Increased bleeding on probing is also observed in patients who are on drug regimens such as aspirin or anticoagulant therapy and during pregnancy. 64 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ROBING M EASUREMENTS (C ONT.) Bleeding (cont.) Reduced bleeding and suppressed clinical signs of gingival inflammation are observed in smokers as a result of the effects of nicotine on periodontal tissues and cellular functions. The number of years of smoking exposure and the number of daily exposures (dose) may also increase the smoking-associated risk of periodontal disease. Suppressed inflammatory response is reversible on smoking cessation. 65 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ROBING M EASUREMENTS (C ONT.) Suppuration Suppuration, also called purulent exudate or pus, in combination with periodontal pockets, and bleeding on probing can indicate that a site is in an active disease state and attachment loss is increasing. Suppuration is formed on the inner pocket wall, but the external appearance of the pocket may be unchanged. Suppuration does not occur in all periodontal pockets; however, its absence is not an indicator of periodontal stability. 66 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ROBING M EASUREMENTS (C ONT.) Clinical assessment of pus within a periodontal pocket is performed by gently placing a finger against the marginal gingiva and pressing toward the crown of the tooth as demonstrated in the following figure. 67 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

F URCATION I DENTIFICATION AND M EASUREMENT The presence, type, location, and extent of involvement of furcations affect the treatment and prognosis of a tooth. 68 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

F URCATION I DENTIFICATION AND M EASUREMENT (C ONT.) A furcation probe, such as the Nabers series probe, is one of the primary furcation diagnostic tools as demonstrated in the following figure. 69 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

F URCATION I DENTIFICATION AND M EASUREMENT (C ONT.) The type of furcation present in a two-rooted tooth is bifurcation involvement. The type of furcation present in a three-rooted tooth may be either bifurcation or trifurcation involvement, if the furcation involves all three roots. 70 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

F URCATION I DENTIFICATION AND M EASUREMENT (C ONT.) Horizontal and vertical bone loss within a bifurcation or trifurcation root are used to determine the degree of involvement. The horizontal component is the measurement of bone loss horizontally under the anatomic crown of the tooth. The vertical component is the measurement of bone loss within the bifurcation or trifurcation vertically from the roof or dome of the furcation to the current bone level. 72 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

F URCATION I DENTIFICATION AND M EASUREMENT (C ONT.) Horizontal and vertical bone loss measurements are illustrated in the following figure. 73 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

F URCATION I DENTIFICATION AND M EASUREMENT (C ONT.) Once a bifurcation or trifurcation is found, further investigation should be performed to determine its cause. Radiographic images can be instrumental in this assessment. Teeth with furcation involvement have been shown to be at greater risk for continued bone loss and tooth loss. 74 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

F URCATION I DENTIFICATION AND M EASUREMENT (C ONT.) A curved, calibrated furcation probe is designed to adapt to furcations as demonstrated in the following figure. 75 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

T OOTH M OBILITY P HYSIOLOGIC M OBILITY Tooth mobility can be an indicator of periodontal disease or another pathologic condition. All teeth have a slight degree of mobility because they are supported by the periodontal ligament. This tooth mobility is termed physiologic mobility. Physiologic mobility may vary in different teeth and at different times of the day. 76 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

T OOTH M OBILITY P ATHOLOGIC M OBILITY Pathologic mobility is horizontal or vertical movement of a tooth beyond its physiologic limits. It is caused by factors affecting the periodontal ligament space and loss of alveolar bone. The amount of pathologic mobility depends on the severity and distribution of the bone loss around each tooth, the length and shape of the roots, and the ratio of the crown-to-root length. 77 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

T OOTH M OBILITY O CCLUSAL T RAUMA Occlusal trauma can also cause tooth mobility. Primary occlusal trauma occurs when teeth in a normal periodontium are subjected to excessive occlusal forces that cause pathologic mobility. Abnormal occlusal habits, such as grinding (bruxing) and clenching, are common causes of tooth mobility. Secondary occlusal trauma occurs when teeth in a compromised periodontium become mobile because they cannot withstand normal occlusal forces. 78 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

T OOTH M OBILITY I NFLAMMATORY C HANGES Gingival inflammation extending into the periodontal ligament can increase tooth mobility, even in the absence of bone loss. Increased mobility is often observed after traumatic injury to the mouth and after surgical periodontal therapy, restoration placement, or endodontic therapy. Mobility is graded according to the ease and extent of tooth movement. 79 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ATHOLOGIC M IGRATION OF T EETH Pathologic migration is tooth displacement that occurs when the balance among the factors that maintain physiologic tooth position are disturbed. Pathologic migration is commonly associated with periodontal disease. The teeth may move in any direction. Pathologic migration in the occlusal or incisal direction is termed extrusion or elongation. 80 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ATHOLOGIC M IGRATION OF T EETH (C ONT.) Occlusal forces against weakened periodontal support, primarily bone loss that renders the teeth unable to maintain normal positions in the arch, may also cause pathologic migration. Pathologic migration arises from a lack of periodontal support, not necessarily from abnormal occlusal forces, and is frequently observed in maxillary anterior teeth. 81 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ATHOLOGIC M IGRATION OF T EETH (C ONT.) The presence of pathologic migration will also increase tooth loss. Unreplaced missing teeth will change the occlusal forces; teeth will drift into the empty spaces. In the molar region, drifting is primarily in the mesial direction. When the first molar is missing, the bicuspids may drift distally. 82 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ATHOLOGIC M IGRATION OF T EETH (C ONT.) Pathologic migration leads to spaces between teeth, which are called diastemas or diastemata. These spaces can lead to food impaction, tooth caries, gingival inflammation, and pocket formation, followed by bone loss and tooth mobility. 83 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ATHOLOGIC M IGRATION OF T EETH (C ONT.) The following figure demonstrates an example of severe pathologic tooth migration. 84 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ERIODONTAL S CREENING AND R ECORDING S YSTEM The periodontal screening and recording (PSR) system is a simplified periodontal assessment system. A specially designed periodontal probe is used with a ball tip and colored calibrations at 3.5 and 5.5 mm. The dentition is evaluated by sextants, and six sites on each tooth are measured. 85 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ERIODONTAL S CREENING AND R ECORDING S YSTEM (C ONT.) A PSR code is assigned to each sextant. The code that most accurately describes the most periodontally involved tooth in a sextant is assigned to that sextant. A full mouth periodontal examination should be performed when: Two or more sextants are scored code 3. One sextant is scored code 3 and code 4. One sextant is scored code 4. 86 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ERIODONTAL C ONSIDERATIONS OF I MPLANTS The clinical assessment of implants includes an evaluation of the soft tissue and supporting structures surrounding an implant. An implant is considered to have peri-implant mucositis when inflammation of the soft tissue surrounds the implant. Inflammation that progresses to include a loss of the peri-implant bone is an indication of peri- implantitis. 87 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ERIODONTAL C ONSIDERATIONS OF I MPLANTS (C ONT.) An implant assessment includes: Documenting the location of implants on the dental records Identifying the presence and location of plaque biofilm and calculus Documenting and evaluating gingival color, contour, consistency, and texture 88 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ERIODONTAL C ONSIDERATIONS OF I MPLANTS (C ONT.) Probing should be performed using a standard periodontal probe and applying light pressure. Healthy implants generally have probing depths of approximately 3 to 4 mm. Probing depths of 6 mm or greater are an indication of peri-implantitis. The maintenance of baseline probing depths is an indication of peri-implant stability. An increase in peri-implant probing depths is a sign of bone loss. 89 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ERIODONTAL C ONSIDERATIONS OF I MPLANTS (C ONT.) Bleeding on probing is indicative of inflammation in the peri-implant mucosa and a predictor for the loss of implant support. Clinically visible suppuration is also a sign of infection and progressive peri-implantitis. Implants with mobility have a lack of osseointegration. Radiographic imaging is recommended to monitor bone height. 90 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

D OCUMENTATION OF P ERIODONTAL A SSESSMENT The patient record must be comprehensive and systematic to provide the necessary information for the diagnosis, planning, implementation, and evaluation of dental and dental hygiene care. Computerized charting and electronic patient records are becoming increasingly common, although paper-based charts are still in use. 91 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

D OCUMENTATION OF P ERIODONTAL A SSESSMENT (C ONT.) A paper-based periodontal charting record is demonstrated in the following figure. 92 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

D ENTITION A SSESSMENT The dentition assessment includes the evaluation of the teeth for: Caries Restoration status Presence of implants Proximal contact relationships Anomalies of form Evidence of parafunctional habits Tooth wear conditions Tooth sensitivity 93 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

C ARIES Caries assessment includes visual, tactile, and radiographic images: Visual assessment includes cavitated and white spot lesions. Tactile assessment includes tacky, sticky, or leathery surfaces, including root surfaces. Radiographic assessment includes radiolucent areas in the tooth structure on images. Transillumination may be used to identify fractures or other alterations in the surface layers of tooth structure. 94 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ESTORATION S TATUS Assessment of restoration status includes documentation of: Existing restorations Poorly contoured restorations Removable prosthetic appliances Implants 95 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ROXIMAL C ONTACT R ELATIONSHIPS Open contacts permit food impaction that may affect periodontal health. Tight contacts may discourage patient compliance with interproximal plaque biofilm removal. Proximal contact relationships can change over time, based on physiologic or pathologic tooth migration, marginal ridge defects, or parafunctional habits. 96 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

A NOMALIES OF T OOTH F ORM Anomalies of tooth form include enamel and dentinal defects and abnormal anatomic formations. The following figure demonstrates an enamel projection. 97 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

P ARAFUNCTIONAL H ABITS Parafunctional habits subject the teeth to forces outside the normal scope of functional occlusion. These include tooth-to-tooth contact, contact between teeth and soft tissue, and contact between teeth and foreign objects. All parafunctional habits can result in damage to the periodontal and tooth structures and soft tissues of the oral cavity. 98 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

T OOTH W EAR Tooth wear is the loss of tooth structure caused by chronic destructive processes other than dental caries. These destructive processes include: Abrasion Abfraction Attrition Erosion 99 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

T OOTH W EAR (C ONT.) Abrasion Abrasion is the wearing away of tooth structures from excessive abrasive forces by a foreign object. Types of abrasion include: Toothbrush abrasion, which may be a result of: Brushing technique, typically horizontal scrubbing Frequency of and amount of time spent brushing Forces applied during brushing Type and hardness of toothbrush bristles 100 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

T OOTH W EAR (C ONT.) Abrasion (cont.) Acidity of the oral cavity, caused by acidic foods and beverages, regurgitation, and acid reflux, can cause abrasions. Dentifrice agents used to clean teeth may cause abrasions. Personal habits, such as fingernail or thread biting and holding foreign objects with the teeth (e.g., pipe stem), may cause abrasions. 101 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

T OOTH W EAR (C ONT.) Abfraction Abfraction describes a cervical V- or wedge- shaped lesion that is generally located apical to the cementoenamel junction in incisors and premolars. Microfractures in the enamel and dentin that are linked to large eccentric occlusal loads are thought to cause these lesions. The cause of abfraction lesions is considered multifactorial. 102 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

T OOTH W EAR (C ONT.) Attrition Attrition occurs primarily on the occlusal and incisal surfaces of the teeth that are exposed to tooth-to-tooth contact. It can occur on any surface exposed to tooth-to-tooth contact. Reduced salivary flow may contribute to tooth wear as a result of increased tooth-to-tooth friction. 104 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

T OOTH W EAR (C ONT.) The following figure demonstrates buccal and lingual surfaces of anterior teeth in a deep overbite relationship. 105 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

T OOTH W EAR (C ONT.) Erosion Erosion is the loss of enamel and dentin, primarily by the chemical action of acids other than those produced by oral bacteria. Dietary and gastric acids are the most common causes of dental erosion. Dietary erosion is most commonly observed as moderate, generalized erosion of the cervical, buccal, and lingual surfaces of the maxillary teeth and of the occlusal and buccal surfaces of the mandibular teeth. 106 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

T OOTH W EAR (C ONT.) The Basic Erosive Wear Examination (BEWE) was designed as a simple index for use in dental practice. The most severely affected tooth in each sextant is scored. All sextant scores are added together to provide a general index of a patients tooth wear condition. Risk levels for the BEWE are: None: Cumulative score of 0 to 2 Low: Cumulative score of 3 to 8 Medium: Cumulative score of 9 to 13 High: Cumulative score of 14 and above 108 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

D ENTINAL S ENSITIVITY OR H YPERSENSITIVITY Patients frequently report pain or sensitivity related to their teeth. The most common stimuli are: Thermal Mechanical Chemical 109 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC I MAGING Radiographic Assessment Radiographic images are an essential adjunct to the clinical examination. They play an integral role in assessing the destruction associated with periodontal disease. Radiographic images permit comparisons of changes in periodontal status over time. These images are indicators of past disease, not active disease. 110 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC I MAGE S URVEYS OF THE P ERIODONTIUM Radiographic images include horizontal and vertical bitewing, panoramic, and periapical images. Bitewing radiographic images are used to detect the bone height of the interdental septa. Horizontal bitewing images are used for patients without periodontal disease. Vertical bitewing images are used for patients with moderate-to-advanced periodontal disease. 111 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC A PPEARANCE OF THE P ERIODONTIUM The radiographic evaluation of bone changes is primarily based on the appearance of the interdental septa. The interdental septum has a thin radiopaque border, referred to as the lamina dura. This border appears radiographically as a continuous white line. The periodontal ligament space appears as a thin radiolucent line between the lamina dura and the tooth root. 112 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC A PPEARANCE OF THE P ERIODONTIUM (C ONT.) Illustrated in the following figure are the radiographic features of the periodontium. 113 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC A PPEARANCE OF THE P ERIODONTIUM (C ONT.) The alveolar crest is angulated rather than horizontal as demonstrated in the following figure. 114 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC C HANGES WITH P ERIODONTAL D ISEASE Interdental Septa In periodontal disease, the interdental septa undergo changes that affect the radiodensity of the crestal cortical plate. Loss of radiopacity occurs, producing a fuzziness in the crestal plate and in the lamina dura at the mesial and distal aspect of the alveolar crest. As periodontal disease progresses, the height of the interdental septum is reduced. 115 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC C HANGES WITH P ERIODONTAL D ISEASE (C ONT.) The following figure demonstrates the early radiographic signs of periodontal disease progression. 116 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC C HANGES WITH P ERIODONTAL D ISEASE (C ONT.) Wedge-shaped radiolucent areas at the mesial and distal aspect of the crest of the interdental septum are demonstrated in the following figure. 117 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC C HANGES WITH P ERIODONTAL D ISEASE (C ONT.) The measurement between the cementoenamel junction and crestal cortical plate is critical for assessing the extent of bone loss. The measurement of normal crestal bone height ranges from 0.5 to 2 mm from the cementoenamel junction. 118 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC C HANGES WITH P ERIODONTAL D ISEASE (C ONT.) When the alveolar crest is approximately parallel to the line drawn between the cementoenamel junctions of adjacent teeth, reduction in the height of the interdental septum is known as horizontal bone loss. When the crest no longer appears parallel to the line formed by the adjacent cementoenamel junctions, the reduction in bone height is known as vertical or angular bone loss. Vertical bone loss is more common in the posterior periodontium than in the anterior. 119 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC C HANGES WITH P ERIODONTAL D ISEASE (C ONT.) Examples of horizontal bone loss are demonstrated in the following figure. 120 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC C HANGES WITH P ERIODONTAL D ISEASE (C ONT.) Furcations Criteria to detect furcation involvement include: 1. Any radiographic change of the periodontal ligament space in the furcation area 2. Diminished radiodensity in the furcation area 3. Significant bone loss in relation to one root of a molar 122 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC C HANGES WITH P ERIODONTAL D ISEASE (C ONT.) Furcation involvements that can be clinically detected are often not visualized in radiographic images as demonstrated in the following figure. 123 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC C HANGES WITH P ERIODONTAL D ISEASE (C ONT.) Root Fractures Root fractures may be horizontal or vertical and may or may not be detected by radiographic assessment. Horizontal root fractures appear as radiolucent lines running horizontally across the root. Vertical root fractures are commonly associated with endodontically and prosthetically restored posterior teeth. 124 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC C HANGES WITH P ERIODONTAL D ISEASE (C ONT.) Vertical root fractures are often difficult to visualize on images unless separation of the fractured fragments is evident as demonstrated in the following figure. 125 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC C HANGES WITH P ERIODONTAL D ISEASE (C ONT.) Other radiographic observations may include a periapical and perilateral radiolucency, called the halo appearance, and a lateral periodontal radiolucency of the root as demonstrated in the following figure. 126 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC C HANGES WITH P ERIODONTAL D ISEASE (C ONT.) Radiographic signs of bone loss may need to be supplemented by clinical examinations such as probing depths. The probing depths associated with vertical fractures are often narrow (1 to 3 mm in width) and deep (8 to 10 mm in length) and may not exhibit obvious mucosal signs of gingival inflammation. 127 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC C HANGES WITH P ERIODONTAL D ISEASE (C ONT.) Root Resorption Root resorption can occur after a traumatic injury to the tooth, chronic inflammation of the pulp, or periodontal ligament irritation. Root resorption is the result of the stimulation of the osteoclast cells by infection or pressure. 128 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

L IMITATIONS OF R ADIOGRAPHIC A SSESSMENT OF P ERIODONTAL D ISEASE Radiographic images are two-dimensional representations of three-dimensional structures; therefore they do not reflect the complete extent of bone loss, especially on buccal and lingual surfaces of teeth. Images do not show the internal morphologic features of bone or the depth of the craterlike interdental defects that appear as angular or vertical defects. Deep boney craters between the buccal and lingual plates may be present without any indication of their presence on images. 129 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC A SSESSMENT OF D ENTAL I MPLANTS Radiographic assessment of dental implants includes an examination of the presence of peri- implant radiolucencies and the height of the marginal bone. Bony destruction associated with peri-implantitis appears as saucer-shaped defects on images. A bone loss of 0.5 to 1.5 mm may be observed in the first year after the connection of the abutment to the implant. An annual loss of 0.05 to 0.2 mm may be observed in subsequent years. 130 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

R ADIOGRAPHIC A SSESSMENT OF D ENTAL I MPLANTS (C ONT.) The following figure demonstrates a radiographic survey of a single implant over a 17-year period. 131 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

A DVANCEMENTS IN I MAGING A SSESSMENT OF P ERIODONTAL D ISEASE Advances in imaging technique include digital subtraction radiography (DSR). DSR measures changes in bone density over time and requires two standardized images with similar projection geometry and exposure parameters. DSR can reduce the delay between the destruction of bone and its detection on images by more efficiently using captured information. DSR may also be used to assess the regeneration of bone in response to periodontal therapy. 132 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

T ECHNOLOGIC A DVANCES IN A SSESSMENTS Scientists and clinicians are working toward the development of cost-effective, efficient technologic advancements to aid in the assessment and diagnosis of periodontal disease and other dental diseases. Newer methods include controlled-force probes for measuring clinical attachment loss, automated tooth mobility equipment for measuring the mobility of teeth and implants, risk calculators, microbiologic testing, and genetic analysis. 133 Copyright 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

c hapter 8 clinical assessment copyright © 2014, 2007, 2001, 1996 by saunders, an imprint of...

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