Diagnosis

Detailed Diagnosis of Periodontal Disease

Diagnosing Periodontal Disease

• Dental / Medical Histories
• Clinical Examination
• Digital Dental Radiographs (X-Rays)
• Diagnosis

Diagnosing Periodontal Disease

Before any periodontal treatment is undertaken, a diagnosis must be made. To reach a diagnosis, the patient's dental and medical histories must be taken, a clinical examination must be performed, and dental x-rays (radiographs) must be reviewed. These steps are generally accomplished during the initial consultation appointment. A second consultation appointment may be needed, particularly when additional information must be obtained. This appointment is scheduled to discuss treatment suggestions in detail and to answer all of your questions.

Dental / Medical Histories

For decades we have known that a prime indicator for future periodontal breakdown is a past history of periodontal disease. By taking a dental history and evaluating previous x-rays, we have a better understanding about the rate of disease progression, and can determine what must be done to prevent further breakdown. In the last decade periodontists have also begun to understand that periodontal disease is a result of bacteria interacting with the patient's defense systems. How the patient's body responds to the bacterial (plaque) assault depends on the "host" resistance. Some people are fortunate, and have minor periodontal disease even with poor oral hygiene. For others, the same amount of bacteria may cause advanced periodontal disease and bone loss.

In other words, certain patients are very susceptible to periodontal disease, and these patients must be particularly diligent with their oral hygiene and maintenance to reduce the bacterial challenge. By taking a complete Medical History we can determine if the patient has certain risk factors and may modify treatment accordingly. Below are the most significant general health considerations that may affect periodontal disease susceptibility.

• Smoking - A host factor that CAN be altered, and one that GREATLY increases the risk of disease.
• Diabetes - Increases the risk of disease if not well controlled.
• Stress - Long-term stress may adversely alter the way you fight periodontal disease.
• Hormones - Increases in gingival inflammation is seen with increased levels of estrogen.
• Medications - Dilantin and several common blood pressure medications, calcium channel blockers, may cause gum overgrowth.
• Severe Osteopenia - May result in more jawbone loss, particularly in postmenopausal women.
• Genetics - About one-fourth of the population is genetically more susceptible to periodontal disease. Today we are able to do a simple test for genetic susceptibility.

Clinical Examination

The periodontal examination gives the dentist a complete picture of the periodontal condition of the patient's mouth. This information is needed before an accurate diagnosis can be made. The oral exam is supplemented with information gained from the dental X-rays.

A major focus of the exam is to determine how much bone loss has occurred. When healthy, there is generally a 2-3 millimeter space (sulcus) between the tooth and the gum. This space deepens as bacterial plaque causes bone deterioration, and penetrates down the side of the tooth. This deepened space is called a pocket.

Healthy tooth	Bone loss leading to pocket formation
Using a probe to measure pocket depth and bone loss

Each tooth is measured (probed) (See What is Periodontal Disease?) at six places, surrounding the tooth, to determine the pocket depth. Normally anesthesia is not needed for this charting, which gives the periodontist a blueprint of periodontal changes.

Probe next to healthy gum	Probe inserted sulcus bottom (green line measures 3mm )
Gum inflammation indicating periodontal disease	Probe 5mm into pocket
Sample periodontal charting showing pocket depths, with gum (red) and bone (blue) levels outlined on teeth. "X" indicates a missing tooth. Please click for a larger view

Other important information is collected during the examination, so an accurate diagnosis can be made.

• Gum recession - The amount of recession added to the pocket depth determines total bone loss.
• Furcations - Bone loss into the furcation (where the roots separate) of a tooth compromises the prognosis.
• Amount of attached gingiva - Without adequate attached gingiva, recession may occur.
• Occlusion (bite) - Excessive forces on teeth may increase the chances of bone loss.
• Tooth mobility (looseness) - Generally indicates inadequate bone support or a bite problem.
• Patient oral hygiene - Poor brushing and flossing will greatly compromise the long-term result.

Digital Dental Radiographs (X-RAYS)

A good series of dental x-rays is mandatory to accurately evaluate periodontal disease. They help determine the amount and location of bone loss, the size and shape of the roots, the amount of root still embedded in bone, the relationship of the teeth to each other, whether the nerve in a tooth has died, the location of the sinus and mandibular nerve when placing implants, and oral pathologies, among other things. We are not able to treat a patient unless we have adequate x-rays. The exception is gingival grafting, which normally does not require X-rays.

There are a number of different types of dental x-rays, each with a specific purpose, but for periodontal treatment a complete series of periapical films is generally required. Below is a list of the commonly taken x-ray views, and the indications for each.

• Full Mouth Periapicals - 16 - 18 detailed views of the teeth and surrounding bone, necessary for an accurate periodontal examination.
• Panograph - A single screening film showing an overview of the upper and lower jaws, sinus, temporomandibular joint, and other anatomic features.
• Bitewings - Four detailed views of the side and back teeth, primarily used to detect decay. Often used with the panograph by general dentists for routine new patient screenings.
• Vertical Bitewings - Four to seven detailed views of the teeth that can show both decay and bone levels when severe bone loss has not occurred.
• Digital X-rays - Any x-ray that is stored digitally, on a computer. Our X-rays are all digital.

Many people have a legitimate concern about the amount of radiation they receive with dental x-rays. It's un-nerving to watch the technician set the machine and run out of the room to expose the film! However, recent advances in dental x-rays make this an unnecessary concern. The film "speed" has improved dramatically, meaning that very little radiation is needed to expose the film. In fact, it is estimated that the amount of body radiation received with a complete mouth series is much less than one would receive at a day at the beach.

We now exclusively use digital X-rays which allows us to decrease the radiation to the lowest levels and results in higher image quality than ever before.

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Diagnosis

Once the clinical data is gathered and correlated with the x-ray findings, we are able to organize and systematically evaluate the results to make a diagnosis. This is critical, for while there may be various approaches to treat a problem, there can be only one correct diagnosis. Once the diagnosis is determined, various treatment options can be formulated. With this information the periodontist and the patient can determine which treatment plan to follow.

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