Perio Lecture # 3

‫ﺑﺴﻢ اﷲ اﻟﺮﺣﻤﻦ اﻟﺮﺣﻴﻢ‬ I wrote this lec. without slides so I advise u to have a copy while u reading it

The unique thing about perio patients (pt) that they come to clinic without pain, they usually refer to periodontist from other dentists without knowing the reasons or what's happening to their gingival. Our- duty as dentists to treat the pts and giving them many advises to keep their gingiva in a health way because: The health of gingiva is the health of the teeth I mean: Nice teeth = nice gingival that reflect our beauty. And this needs a well trained to make a complete check up and decide what the treatment plan is. The Dr. here showing us a picture for a normal gingival (plz refer to slide but I don't know the page #) its pink in color, scalloped shape (knife shape edge), no swelling A student said it's stippled….although it’s a normal feature but we can't noticed it by looking at a picture. Now about the signs of inflamed gingival: Pain, swelling, and bleeding.

Comprehensive periodontal examination • •

Medical history ( M.H ) Dental history ( D.H )

What's the importance of M.H? HIV pts??? Can a pt that comes to ur clinic tells u that he has a virus or a disease like this??? Of course not so how can we know or discover these pts? By talking with them because we can't force pts to do blood test. Other common diseases that we should be careful during examine pts is diabetic mellitus and comma one of its complication (the dr. told us that it's our problem to know the information about this topic) and a cardiac disease (a pts who have a problems in heart valves) ……………………………………….. ………………………………………… After making a M.H we remove to D.H We have 2 types pf pt: Regular that visit dentists continuously for check up Irregular those only visit dentists when they have pain!!!!

Extra oral examination • • •

Skin Lymph-nodes Muscles

Intra oral procedures and data: Recording / visual (gathering data to understand what's going on to the pt) ‫ﻳﻌﻨﻲ ﻣﻨﺎﺧﺪ ﻗﺮاءات ﻟﻠﻤﺮﻳﺾ ﻷﻧﻪ ﻣﻤﻜﻦ ﻃﺒﻴﺐ اﻷﺳﻨﺎن ﻳﻔﺤﺺ اﻟﻤﺮﻳﺾ ﻣﻦ دون ﻣﺎ‬ ‫ﻳﺸﻮﻓﻪ ﻳﻌﻨﻲ ﺑﺲ ﻳﺴﺄﻟﻪ أﺳﺌﻠﺔ وﺑﻌﺪﻳﻦ ﺣﻴﻴﺠﻲ اﻟﻄﺎﻟﺐ ﻳﻘﺮأ آﻞ هﺪﻟﻮل اﻟﻤﻌﻠﻮﻣﺎت أدام‬ . ‫اﻟﺪآﺘﻮر اﻟﻤﺴﺆول ﻋﻨﻪ ﺑﺲ ﻻزم ﻳﻌﻄﻴﻪ ﻓﻜﺮة ﺷﺎﻣﻠﺔ وﺑﻌﺪﻳﻦ ﻳﺤﻜﻮا ﻋﻦ ﺧﻄﺔ اﻟﻌﻼج‬

Plz refer to slides here I think there is more talking .

What are the reasons NOT to have enough keratinized gingiva: 1. 2. 3. 4. 5. 6. 7.

The vestibule is shallow Caries Agenda Smoking Toothbrush Occlusion trauma Buccal frenum (high attachment may make gingival stretching and recession).

The most important thing we should know in perio course is the instrumentation Periodontal probe for pocket depth which has multiple variations in their graduation . It may be graduated as 3, 5, and 7 William probe that we use 1,2,3,5,7,8,9 Evaluation procedures: it means read-tissue and assess anything like color, texture and if we have edema, bleeding (red spots on a pocket), exudates (E) a pus on the apex of the inflamed root.

Pocket depth (PD): Distance between gingival margin (G.M) and the depth of craves sulcus Either the G.M on the gingiva or incisal 1/3 we should step around the tooth from side to side... I wrote the way in my words cz the record here was so bad

Try that the insertion of PD probe in the gingival sulcus or PD pocket between the surface of the tooth and gingival to be parallel to the long axis of the tooth because as you change the angulations of it: the reading will change. The way that we measure the probing depth is walking method, insert the probe at distal surface and move it until reach the mesial surface without removing it from the sulcus(walking ) and I record the deepest point ‫ﻷﻧﻪ ﻣﻤﻜﻦ اﻟﺒﺮوب ﻳﻜﻮن ﻣﺎﺷﻲ ﻣﻌﻚ ﻣﻦ ﻧﺺ اﻟﺴﻦ ﺑﺲ ﻳﺪﺋﺮ ﻣﻌﻚ ﻋﻠﻰ اﻟﻄﺮف‬ So just we want to know how much gingival de attached from the tooth We enter the probe which is already divided into parts If we get a reading 5-6 mm we prefer to take 6 mm (always take the deepest point) To be more careful in treatment plane

Note: The healthy M.G is 2 mm from cemento enamel junction coronally but if we have M.G below CEJ we call it recession (it’s a repetition I know)... PD is not reflecting a real disease mm ٤ ‫ ازا آﺎن اآﺘﺮ ﻣﻦ‬P ‫ﻧﺤﻨﺎ ﺑﺎﻟﻌﻴﺎدة ﺣﻜﺘﻠﻨﺎ اﻟﺪآﺘﻮرة ﻋﺎدة ﻣﻨﻌﺘﺒﺮ ﻓﻴﻪ ﻋﻨﺎ‬ But as beginners we score any reading we get it... The only thing that reflects a real disease is CAL

What's CAL ? Its clinical attachment level measured by perio probe from CEJ to gingival sulcus (I think it means the loss of attachment) The probing depth is not reliable to determine if there is attachment loss because the reference point in measuring it is a soft tissue which is not fixed (ex: if it is inflamed it will be enlarged and got higher position and when it heals it will return to lower position so we need fixed position to measure the attachment so we depend on the measurement of clinical attachment level CAL).

3 cases: 1. When we have a recession: CAL = PD + recession Gingival recession is the distance b/w CEJ and gingival margin .

2. When we have over growth CAL = PD – space coronally to CEJ 3. G.M coincide with the CEJ : PD = CAL

Here the Dr. shows us an examination form that we will use in perio course:

Some notes:

• About M .H we concern about smoking and the dentist can persuade the smokers to leave this habit more than the general doctors in medicine • About the way that the pt brush his teeth and if he is doing that in a wrong way we should advise him. Auxiliary aid: I mean flossing and brushing because the toothbrush can't reach all the surfaces in the tooth so it's better to do flossing. Periodontal disease is the disease that affects the periodontium and the majority of them are inflammatory periodontal disease which means that the initiating factor or cause of this disease is bacteria which are present in the dental plaque. So the first enemy that we are facing here is the PLAQUE. Accumulation of dental plaque the product of bacteria lead to the inflammatory process and the progression of these inflammatory process might cause more destruction in periodontium including PDL,alveolar bone, forming true pocket and t this disease stage we call it periodontitis but at the beginning of inflammation when it is confined to gingival we call it gingivitis. So gingivitis

more progression

periodontitis

And here the Dr started talking 3 minuets about some medicine information; I didn’t hear clear but the general idea is the perio disease like a chronic disease, its multi-factorial reasons and has a relation with a growth factors, IL, and c-creative protein which is a protein build up in liver and activate a complement system to facilitate the phagocytes process.…. To be continued…………….

Done By: Aseel Aref Al-Momani

The second part of the lecture…. Done by: Abdullah t. Al-Halhouli. • The gingival index(GI) was developed by Low and Silness 1963 to describe the clinical severity of gingival inflammation as well as its location. -The GI depend mainly on bleeding so we pass the probe on the marginal gingiva and see if that cause bleeding or changing in the color of the gingiva. -The GI describe the clinical changes not the histological one because the normal flora of the oral cavity cause neutrophil infiltration to gingival tissue But it could be clinically healthy. Points Appearance 0 Normal 1 Slight change in color and mild Edema with slight change in texture 2 Redness ,hypertrophy ,edema and glazing 3 Marked redness ,hypertrophy , Edema ,ulceration

Bleeding No bleeding No bleeding

Bleeding on probing/pressure Spontaneous bleeding

Inflammation none mild

moderate

Severe

Notes: 1. Spontaneous bleeding : it is the bleeding that happened when the patient eat or touch his gingiva so it is not sever bleeding. 2. If patient come to your clinic and he is smoker,( PD>3)and his teeth are mobile and furcational involved but there is no bleeding on probing we called this Masking. This happened because smoking effect the vascularity and cause tissue ischaemia. 3. The gingiva clinically health only when GI=0. 4. Measuring probing depth clinically by stepping around the tooth.

• CAL(Clinical Attachment Level): measured by perio- probe from the cemento-enamel junction(CEJ) to the bottom of the periodontal pocket or gingival sulcus. -The measurement of CAL depend on the gingival margin position which could be: 1. Enlarged(over growth):the gingival margin is coronal to the CEJ. (CAL=PD – over growth) 2. Normal. (CAL= PD) 3. Recession: the gingival margin is apical to CEJ. (CAL =PD + gingival recession) -For example if a site has 2mm of recession and PD=5 CAL=7mm(5mm+2mm),But if the gingival margin is located 2mm coronal to CEJ and 5mm PD is present CAL=3mm(5mm-2mm). Notes: 1. We use the probe to push away the gingival from the tooth to see the CEJ so you have to know the anatomy of the tooth. 2. In class 5 restoration the base of restoration will be your landmarks because the restoration invade the CEJ.

• Limitation of probing: 1. Angle: you step around the tooth according to it is anatomy. In page 5 the upper left slide you can see that when the probe away from the root the crestal bone prevent the probe to reach the full pocket depth. 2. The force(pressure): minimum force=25gram (perfect) maximum force = 75 gram. 3. Diameter and shape of probe tip: it should be pointed and its diameter=0.5mm 4. Tissue inflammation: the inflammation cause overgrowth and swelling of gingival margin(deep PD).After healing of inflammation PD decrease. 5. Visible reference points: probing of the anterior teeth easer than the posterior teeth.

• Intraoral procedures data recording: -Sounding(Transgingival probing): using the probe to know the thickness of gingiva by this we know where is the bone, we do sounding when we do implantation. The thick of gingiva= (1.5 mm - 3 mm) and it could be( 5 mm) if there is tooth extraction.

• Furcation Examination: -We use Nabors probe to do this examination which is curved and more pointed. Glickman system to classify furcation involvement: - Class 1 : Incipient lesion. - Class 2 : Bone destroyed on one or more aspects of furca, partial penetration of probe into furcation.(the probe doesn’t pass from buccal to lingual) - Class 3 : Interradicular bone absent but orifice of furca is occluded by gingival.(the probe pass from buccal to lingual) - Class 4 : Furca opening visible. Note: -In class 1,2 and 3 the gingiva cover the furca opening but in class 4 it is not. • Explorer : which we use in conservative clinic for: 1. Caries. 2. Restorative margins. 3. Calculus. • Mobility: Methods to measure mobility: 1. Handles of two hard instruments(Probe & Mirror). 2. Handle of one hard instrument and one finger(Thumb). -The mobility could be BL,MD & vertical. Miller Mobility Index: - Class 0 : no mobility greater than normal physiological mobility. - Class 1 : the first distinguishable sign of movement greater than normal. - Class 2 : movement of the crown up to 1mm this movement could be BL & MD but not vertical depression movement. - Class 3 : movement of the crown more than 1mm in any direction and/or vertical depression or rotation of the crown in its socket(Hypermobility).

• Occlusal Evaluation: If there is high restoration it will cause occlusal truma ,widening to PDL and bone loss, we should improve the occlusion.

-occlusal truma without plaque will not cause socket or PDL disease.

• Interpretation of radiographic feature: -The best film is the vertical bitewings. -periapical radiograph to see the apex and all the anatomy of the tooth and if the tooth pulp involved or not. Limitation of radiograph: 1. Exposure. 2. Angulation. 3. Processing. 4. Film position and film type. 5. Projection geometry. 6. overlapping structure(Bone & Teeth). 7. Assumption made in interpretation of images of osseous structures. -the distance from CEJ to bone crest in health = (1mm – 2mm) Type and number of radiographs needed: 1. Panograph and vertical bitewings for gingivitis and slight periodontitis. -we do two vertical bitewing radiographs and periapical radiograph for anterior teeth, but in other country they do full CMS for all the teeth. 2. CMS with vertical bitewing radiographs for moderate and severe. -In page 7 you can see the type of bone loss which could be: 1. Vertical : angle in shape. 2. Horizontal.

• Periodontal charting: Average PI= sum PI / numbers of teeth. Average GI= sum GI/ numbers of teeth. Guideline for completing the periodontal worksheet: • For BOP place a red dot at bleeding site where PD is documented. • Mobility value(I-III) is printed on the occlusal surfaces of mobile teeth.

• Draw recession on the root with red pencil, every line in the sheet=1mm.

• x :missing tooth. • For furcation involvement use a red pencil and follow Glickman system: - Class I : V - Class II: ∆ - Class III: ▲

The End Of The Lecture

Done by: Abdullah T. Al Halhouli.

Life is not measured by the breaths we take, but by the moments that take out breath away