Art of history taking in periodontics

Case history recording is the first and the most important step in the treatment of a patient. A correct diagnosis leads us to a correct treatment plan. The case history is a planned professional conversation with the patient that enables the patient to communicate their symptoms. The interest, warmth, and compassion exhibited by the clinician during history taking helps in establishing a rapport with the patient and to gain the confidence of the patient. A good clinician starts examining the patient when he/she walks into the room. Ideally, the case history should be recorded in a consultation room or a private room, so that the patient is free of the anxiety of dental operatory room. The clinical examination is done in dental operatory in a calm and friendly atmosphere. A proper clinical and radiographical examination can reveal many other findings which help us to find out associated problems in a particular case thus helping us to provide a good periodontal health and a functional occlusion to the patient. Figure 39.1 describes the sequence of various steps involved in the recording of case history.

Biographic and demographic information

This is the first step in history taking where we record patient’s name, address, and telephone number; identification number (e.g. social security number); age (date of birth); gender; race or ethnicity; name, address and telephone number of the referring dentist or physician, as well as that of the dentist(s) and physician(s) whom the patient consults for routine problems; and insurance and billing data which is usually handled by clerical personnel and is readily computerized. The accuracy of the data provided by the patient should be confirmed.

Name:

It is very important to know the patient’s name. It helps us to develop a personal bond with the patient and also the patient feels that the doctor is not treating him like just another case. It also helps in eliciting the case history as well as psychologically the patient is assured that the doctor is giving him personal attention. In pediatric patients, addressing the child by his/her name/ pet name facilitates the child to talk freely.

Age:

It is important to know the age of the patient because many conditions are more common in certain age groups. For example, gingivitis and bleeding gums are often seen during puberty. Aggressive periodontitis cases are usually young patients, whereas chronic periodontitis cases are usually old patients. Wasting diseases like attrition and abrasion are more common in elderly patients. Furthermore, the behavioral management of the patient depends on the age of the patient. In pediatric patients, the clinician, as well as parents, play an equally important role in rendering the treatment to the child, whereas, in adult patients, there is one to one communication between the dentist and the patient.

Gender:

Certain diseases are more common in a particular gender. For example, localized aggressive periodontitis with circumpubertal onset has been shown to be more common in females as compared to males 1. However, presently it is a controversial issue because studies suggesting both, higher distribution of disease in females than males 2, 3 and no sex predisposition 4, 5 are there. Genetic polymorphisms are commonly associated with severe periodontal diseases. These may also be unequally expressed in males and females. Osteoporosis is the disease associated with a decreased bone density. It is usually found in postmenopausal women due to the decrease of estrogen levels in the body. It is well established that estrogen maintains the bone mineral density and its decreased levels are associated with a decrease in bone mineral density. Moreover, it has been observed that women are more proactive than men in maintaining their teeth and periodontal health.

Religion:

It is importnat to know the religion of the patient because unknowingly we should not hurt the religious sentiments of the patient. For example, Muslim women cover their hair and neck with a headscarf called a ‘hijab’, which they wear in the presence of the opposite sex. It may pose a problem for dentists as it may interfere with a required extra-oral examination. In some cases, we can see women covering their face, which causes difficulty for a dentist to examine her oral cavity. Careful consent is required in examining and providing treatment for such patients. If a female dentist is available with the working unit, she should take care of these patients. Muslim men avoid wearing gold jewelry. So, gold restorations should be done after consent of the patient.

In Hindu religion, eating of animal meat is prohibited. Some patients may object to certain dental materials, which they think may consist of animal parts. So, it becomes important to assure these patients regarding the materials used in their treatment. In many religions intake of alcohol is prohibited. Strict followers of these religions are apprehensive about the materials used during the treatment as it may contain alcohol as one of its constituents. So, the dentist should be aware of any religious and cultural rituals that impact on the management of the patient in order to treat the patient with empathy and understanding.

Social status:

The relationship between socio-economic status (SES) and oral health is well-established. It has been shown by many different studies that economically sound and socially well-placed people have less dental problems owing to awareness as well as frequent visits to the dentist. On the other hand, people with poor social status have more dental problems due to ignorance of oral hygiene and fewer visits to the dentist as well as the lack of dental insurance.

Occupation:

One of the most important risk factors associated with oral health today is stress. Many people have dental and periodontal problems because they have occupational stress. This is especially with those people who have public dealings every day and are subjected to work overload. These patients usually have gingival inflammation, which if ignored may lead to periodontitis. Another problem that is commonly associated with mental stress is attrition of teeth.

People working in chemical factories usually have tooth erosion associated with dentinal sensitivity. In certain occupations, the workers are exposed to abrasive dust in the environment that may cause severe attrition. Health care workers such as nurses may become carriers of transmissible diseases if infected by the patient. Sex workers and people who frequently stay away from home are at more risk of having sexually transmitted diseases like AIDS, syphilis etc. So, while treating these patients, a special care should be taken regarding disinfection and sterilization. Occupation also affects the patient’s understanding of diseases as well the treatment plan. Well-educated patients easily understand their dental problem as well as the importance of its treatment.

Address:

Address helps in communication with the patient. It also helps to assess the availability of dental health facilities in the area where the patient resides. Patients follow up visits should be reduced if it is difficult for him to come frequently. Certain diseases have a geographical distribution. This distribution may be in different villages or event different parts of a city. For example, fluoride levels in different drinking water sources may vary. It results in the fluorosis in the affected area where fluoride levels are more the optimum. The personal habits of the patient also vary according to geographical distribution. For example, in certain parts of the world, tobacco is smoked, whereas in some other parts it is mostly chewed in different forms. The resulting diseases with both of them are different. Tropical diseases can be seen in tropical countries.

Periodontology case history record

Chief complaint

The chief complaint consists of a brief statement, preferably in the patient’s own words, concerning his reason for seeing the dentist. Actually, in the past the term “chief complaint” was used for a single problem as the patient commonly used to see a dentist for a single illness. The patients rarely sought relief for chronic, multiple, interacting problems as they do today. “Active problems” is a better term to explain patients’ presenting problems. For example, a patient with few remaining teeth has pain in a particular tooth and says “I want treatment for this painful tooth as well as artificial teeth to replace missing teeth.” So, in this case, both the problems are important: pain in the tooth as well as the inability to eat due to missing teeth. The active problems of the patient should be recorded in a chronological order. If these problems started simultaneously, these should be recorded in the order of severity.

Ideally, open-ended questions like “What brings you here? How can I help you? What seems to be the problem?”, are a good way to start with. It is important to hear the patients describe the problem in their own words. Push them to be as descriptive as possible. Once the patient has described his/her problem in detail, we can go ahead with our questions focused on finding out the complete detail about the problem. While explaining the active problems, the patient should not be interrupted, if possible.

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History of present illness

A detailed description of the patient’s current problem(s) in a chronological order is called the “history of present illness”. Every symptom and sign have a beginning and a course of development which must be recorded in a chronological order. Usually, a patient reports to a dentist when in pain and/or has swelling.

Pain:

There is a set pattern of questions which must be asked in a sequential manner to identify the complete history of pain. These questions can easily be recalled using the word OLD CARTS (Onset, Location/radiation, Duration, Character, Aggravating factors, Reliving factors, Timing and Severity).

Onset:  The patient is asked about the onset of the pain or problem. Simple question here is “when it started?” For example, if a patient has come with swelling, its onset should be asked. A swelling is usually preceded by pain so everything should be recorded in a chronological order.

Location: The patient should be asked to locate the pain. In endodontic problems the pain is usually sharp and patient can locate it easily, pointing out the concerned tooth. In the case of a periodontal problem, the pain is usually dull and gnawing in nature which is commonly felt deep in the bone, which the patient cannot usually localize to a particular tooth but to a region. Sometimes, the pain is radiated to the temporal region in case of maxillary teeth or towards the angle of the mandible when a mandibular tooth is involved. It should be recorded.

Duration:  The question to be asked here is “ For how long the problem has been there?”  The patient should be asked when he was absolutely fine. This gives us information about the duration of the problem.

Character: As already stated, pain may be sharp or dull in character. Sharp pains are usually associated with endodontic origin, whereas dull pains are usually associated with periodontal origin.

Aggravating factors: The patient should be asked about factors which increase the pain. For example, the endodontic pain is aggravated on lying down. Any thermal stimulus usually aggravates endodontic pain, whereas it may not have any effect on periodontal pain.

Relieving factors: Reliving factors of the pain should be recorded. In periodontal problem patient sometimes is relieved of the pain by forceful clenching of the teeth.

Timing and Severity: If the tooth has reversible pulpitis the pain should last usually within 30 seconds following a stimulus like thermal changes. In the case of irreversible pulpitis, the pain may stay for a longer duration. In both cases, the pain shall be sharp in nature. The periodontal pain may start on its own without any stimulus, is dull in nature and may stay for a variable duration.

Along with the above findings, movement of the pain if any should be noted. Referred, shifting or migrating pain should be recorded in the case history. Sometimes pain may also be accompanied by neurological signs and symptoms. A sensation of hyperesthesia, anesthesia or dysesthesia should be noted, if present.

Swelling:

The duration of the pain should be noted so that it’s chronic or acute nature can be determined. Swelling associated with periodontal abscess usually has an acute onset and has pain associated with it. Sometimes combined endo-perio lesions may involve the facial spaces. Any disfiguring of the face caused by the swelling should be noted. The consistency of the swelling provides us the information of its soft tissue or hard tissue origin. A soft depressible swelling is of soft tissue origin, whereas; a stony hard swelling is of osseous origin.

Past dental history

The past dental history is one of the most important components of the patient history. In this step, we record the patient’s attitude towards previous dental treatment, the frequency of past dental visits, previous periodontic, restorative, endodontic or oral surgical treatment; the reasons for loss of teeth; fluoride history and radiation or other therapy for oral or facial lesions. Any untoward complications in any of previous dental treatment must be asked. If the patient has undergone orthodontic treatment, his/her experience with orthodontic appliances and dental prostheses should be recorded. It is also required to record the names, addresses, and telephone numbers of the dentists involved in the previous dental treatments, especially to get complete information regarding any untoward complications which occurred during previous treatments.

Past medical history

Eliciting a patient’s past medical history is an essential clinical skill. Many medical problems have a significant effect on dental treatment. Often, the patient presents with complicating dental and medical factors such as restorative and periodontal needs coupled with a systemic disorder, such as diabetes. It is important to record any medical ailment, treatment or hospitalization for any reason. Any systemic condition for which patient is presently under treatment and the medication he/she is taking should be recorded. If the patient has undergone any radiation therapy it is important to find out the diagnosis, dose of radiation therapy and  anatomic location of the treatment. In brief, past medical history consists of the following,

Major illnesses, beginning in childhood

The patient should be asked about any illness for which he was on medication. These are illnesses that require physician attention that necessitated staying in bed for longer than 3 days, or for which the patient was (or is being) routinely medicated. The patient should be asked specific questions regarding the illness and a history of heart, liver, kidney, or lung diseases; congenital conditions; infectious diseases; immunologic disorders; diabetes or hormonal problems; radiation or cancer chemotherapy; blood dyscrasias or bleeding disorders; and psychiatric treatment should be taken carefully.

Hospitalization

Hospitalization of the patient indicates serious illness. The record of hospitalization should be studied which is a very important source of the patient’s medical status. It also gives information about any kind of surgical procedure carried out as well as complications that may have appeared during the procedure.

Significant injuries

Many injuries are important from the dental point of view. Any injury with regard to the orofacial region should be recorded. For example, an injury to chin due to falling down may result in the temporomandibular joint problem. Any trauma to teeth may lead to the de-vitalization of teeth.

Medications

Many patients are on medications for systemic diseases, when they come for dental treatment. Complete detail of all the medicines which the patient is taking must be recorded. This is important because during the dental treatment if we want to prescribe a medicine to the patient, any drug interaction should be taken care of. Also, conditions like drug induced gingival enlargement are due to medicines taken by the patient for systemic diseases. The physician should be consulted to change the medication, if possible.

Allergies

Any history of classic allergic reactions, such as urticaria, hay fever, asthma, or eczema, as well as any untoward or adverse drug reaction (ADR) to medications, local anesthetic agents, foods, or diagnostic procedures,  should be recorded. The patient should be asked about the history of fainting, stomachache, weakness, flushing, itching, rash, or stuffy nose, and events such as urticaria, skin rash and acute respiratory difficulties. One important  thing to be noted here is latex allergy. As we work with latex gloves it is important to ask the history related to latex materials. Atopic individuals, patients who have urogenital anomalies, and those with certain disorders such as spina bifida are predisposed to latex allergy 6 .

Immunizations

Immunization is a common procedure these days. Because of the increased prevalence of transmissible diseases, patients without immunization are at a high risk of spreading the disease. For example, if the patient has never been immunized for HBV care should be taken regarding disinfection and transmission of infection from patient to operator.

Transfusions

A history of blood transfusion is important to note because the number of transfused blood units, may indicate a previous serious medical or surgical problem that can be important in the evaluation of the patient’s medical status. Secondly, a blood transfusion may also lead to any persistent transmissible infectious disease.

A brief gynecological and obstetric history for female patients

If a patient is pregnant, care should be taken not to expose the patient to any ionizing radiations.  Surgical treatments should be avoided during pregnancy. If necessary, should be carried out during the second trimester of pregnancy. During pregnancy, use medications only if absolutely indicated. Certain antibiotics (streptomycin, kanamycin, and tetracycline) are best avoided entirely during pregnancy because of their teratogenicity. Antibiotics in category A or category B on the FDA list of approved drugs for use during pregnancy can be prescribed during pregnancy (see “Periodontal treatment of female patients” for detail).

Know more……….

Postural hypotension in pregnant patients:

One major change in the cardiovascular system during pregnancy is increased cardiac output, plasma volume and heart rate. In almost 96% pregnant women a benign systolic ejection murmur, caused by increased blood flow across the pulmonic and aortic valves is noted 7. It requires no treatment, though. In addition to this, because of vasomotor instability, pregnant patients are susceptible to postural hypotension. As the uterus increases in size, it causes pressure on the vena cava and aorta, which can result in decreased cardiac output, venous return, and uteroplacental blood flow. Aortocaval compression, which occurs specifically in the supine position, leads to the supine hypotensive syndrome, which is characterized by symptoms and signs such as lightheadedness, weakness, sweating, restlessness, tinnitus, pallor, decrease in blood pressure, syncope and, in severe cases, unconsciousness and convulsions. Therefore, changes in dental chair position from reclining to upright should be performed very slowly. Patients who experience this syndrome are usually aware of its occurrence and can alert their caregivers if they begin to notice symptoms developing. The condition can be corrected by having the patient roll on her left side and placing a pillow or rolled towels to elevate her right hip by about 15°. This maneuver lifts the uterus off the vena cava and re-establishes aortocaval patency 8.

 

Family History

Gathering a complete and accurate family medical history is very important as the genetic basis of periodontal diseases has been well established. Family members have many factors in common, including their genes, environment, and lifestyle. Many investigations, done on families using pedigree analysis, segregation analysis, and linkage analysis have demonstrated the genetic basis of periodontal diseases. Along with this many systemic diseases like diabetes, which affect the course of periodontal disease progression, also have genetic factors involved. So, systematic inquiry into the possible presence of disease states in the family that might affect the patient’s dental and systemic health should be recorded. This would include information about:

  • Has any family member suffered from the similar disease
  • Do you know any disease that runs in your family
  • Number of siblings with and without the disease
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Personal history

In personal history, a detailed description of patient’s personal habits should be recorded. Patient should be asked about his/her oral hygiene and dietary habits. The patient should also be asked about any kind of adverse habits,, if he/she has any like smoking, tobacco chewing, alcohol consumption as they may also affect the treatment plan. Details should be gathered about the oral hygiene  measured exercised by the patient by asking questions like,

  • How many times do you brush your teeth?
  • What king of toothbrush and toothpaste do you use?
  • What brushing technique do you follow?
  • Do you use any other oral hygiene measue like flossing, interdental aids or chemical plaque control measures ect?
  • How frequently do you replace your tooth brush?

All these details are the indicative of awareness of the patuient about importance of maintenance of oral hygiene. Also, it helps to formulate the treatment plan accordingly and make any required changes in patient’s habits to aid in better post-treatment outcome.

Education level of the patient is also an important factor affecting the treatment planning and long term maintenance of the patient. In general well educated patients are more aware of their oral health as compared to less educated patients.

Table 39.1 A smaple of detailed case history record

Case history record 

Reference No:

Name:                                            Gender:                                                         Age:

Occupation:                                                                 Contact number:

Address:

 

Chief complaint:

 

History of present illness:

 

Past medical history:

 

Past dental history:

 

Personal history:

 

Oral hygiene measures:

 

General physical examination:

 

Clinical examination:

Extraoral examination:

Facial symmetry

Lip competence

Lymph nodes

TMJ

Intraoral examination:

Hard tissue examination

Type of dentition

Number of teeth present

Notation

Caries/decayed

Missing

Filled

Stains/ deposits

Wasting disease

Oclusion

Proximal contact

Plunger cusp/ food impaction

Pathological migration

Any prosthesis

Any other

Soft tissue examination:

Examination of oral mucosa and other structures

Tongue

Lips

Buccal mucosa

Floor of the mouth

Frenum

Soft palate

Hard palate

Vestibule

Examination of gingiva

Colour

Contour

Consistency

Surface texture

Size

Position (recession)

Gingival exudate

Bleeding on probing

Embrassures

McCall festoons

Stillman’s cleft

Periodontal status:

Periodontal Chart

Pocket depth:

Clinical attachment loss:

Mobility:

Furcation involvement:

Tender on percussion:

Periodontal abscess:

Mucogingival finding:

Recession:

Depth of vestibule:

Tension test:

Width of attached gingiva:

Occlusal examination (Fermitus test for trauma from occlusion)

Wax records

 Radiographic examination:

 

Relevant indices:

 

Provisional diagnosis:

 

Special investigations:

Microbiological analysis

DNA analysis for plaque micro-organisms

Immunological investigations

Blood examination

Urine examination

Biopsy

Study casts

Any other specific test

Final Diagnosis:

Prognosis:

Treatment plan:

Preliminary (Emergency phase):

Phase I therapy (Etiotrophic phase):

Evaluation of phase I:

Phase II (Surgical phase):

Post surgical evaluation of the patient:

Phase III(Restorative phase):

Supportive periodontal therapy 

Treatment notes: 

Clinical examination

Clinical examination starts with the general physical examination. The general physical examination consists of checking the vital signs of the patient which are pulse, blood pressure, respiratory rate and body temperature. The general physical examination is followed by an extra-oral examination. In this examination, lymph Nodes, temporomandibular joint (TMJ), facial Symmetry and lip competence are recorded.

General physical examination:

Pulse:

The pulse should be checked for its rate, rhythm, volume, and character. It can be felt by compressing the artery against bone in different parts of the body, such as at the neck (carotid artery), on the inside of the elbow (brachial artery), at the wrist (radial artery), at the groin (femoral artery), behind the knee (popliteal artery), near the ankle joint (posterior tibial artery), and on foot (dorsalis pedis artery). The pulse rate per minute is indicative of heart rate. Pulse rate varies with the age of the patient. In newborn (0-3 months old) pulse rate is 100-150, in infants ((6-12 months) it is 80-120, in children (1-10 years) it is 70-130 and in children over 10 years and adults, including seniors it is 60-100. In well-trained athletes, it is 40-60. Pulse rate lower than normal or more than normal should be noted, if present.

A normal pulse is regular in rhythm and force. There are a number of cardiac conditions which result in cardiac arrhythmias such as……………………

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Blood pressure:

Blood pressure is the pressure exerted by circulating blood upon the walls of blood vessels. The normal range of systolic blood pressure is 90-119 mm of Hg and for diastolic blood pressure, it is 60-79.  It is an important parameter which must be recorded before doing any invasive procedure such as extraction or periodontal surgery. In a hypertensive patient, excessive bleeding is expected. More details regarding hypertension has been given in the chapter 32 “Periodontal management of medically compromised patients”. A low blood pressure is referred to as hypotension. It manifests clinically with various signs and symptoms, such as dizziness, fainting, or in extreme cases, shock. Both hyper- and hypotensive patients should be managed appropriately before going for any invasive periodontal procedure.

Respiratory rate:

The respiratory rate is measured by counting the breaths for one minute when the person is at rest. It can be done by simply observing the chest movement of the patient. The respiratory rate for a healthy adult at rest is 12–20 breaths per minute. It is more in children, with a six-month-old child having a respiratory rate of 25-40 breaths per minute. Tachypnea (fast breathing) is usually seen in fever, hypoxia, shock, metabolic acidosis, hysteria and cerebral disturbances. Bradypnea is observed in the case of cerebral compression. The expiratory wheezing sound is observed in bronchitis and asthma. The respiratory rate of the patient should be kept under observation throughout the treatment of the patient. During syncope or anaphylactic reaction, the change in respiratory rate and its character is an important sign of these conditions.

Body temperature:

The normal body temperature of a healthy individual is 37°C or 98.6 F°. It can be easily recorded with a thermometer. Fever or increased body temperature is a common sign of systemic infection. Sometimes endodontic or periodontal infection may get a systemic access which may cause fever. Space infections are also commonly associated with fever.

Extra-oral examination

Facial symmetry:

Although no face is perfectly bilaterally symmetrical, any change from the normal bilateral facial symmetry indicates some kind of pathology on the affected side. Facial asymmetry can be summarized and divided into three main categories (Table 39.2),

  1. Congenital, originating prenatally.
  2. Developmental, arising during growth with inconspicuous etiology.
  3. Acquired, resulting from injury or disease.
  4. Inflammatory; most common, resulting from endodontic or periodontic origin and involving facial spaces

Table 39.2: Various causes of facial asymmetry

Inflammatory
Developmental
Acquired
Congenital
Due to space abscessUsually, have unknown causeTMJ ankylosis
Unilateral condylar hyperplasia
Facial trauma
Childhood radiotherapy
Fibrous dysplasia
Romberg’s disease
Other facial tumors
Cleft lip and palate
Hemifacial microsomia
Craniosynostosis
Tessier craniofacial cleft
Craniosynostosis
Vascular disorders
Torticollis

Out of the above causes of facial asymmetry, space abscess is one of the most common causes of facial asymmetry.  It can be easily confirmed by the case history of the patient.  Temporomandibular joint pathologies are one of the important causes of facial asymmetry.  TMJ ankylosis is most commonly the result of trauma to the joint. So, a history of a fall or trauma to the orofacial region should be elicited. Congenital abnormalities like cleft lip and palate, hemifacial microsomia, craniosynostosis, Tessier craniofacial cleft, craniosynostosis and vascular disorders are present at birth and cause facial asymmetry.

Lip seal:

Lip seal is a natural seal made between upper and lower lip at rest, without any effort. The lips may be described as,

Competent: Here a lip seal is produced with minimal muscular effort when the mandible is in the rest position.

Incompetent: In this case due to morphologically short upper or lower lip, a lip seal cannot be made in a relaxed state. Lips can only be brought together by the contraction of circumoral muscles.

Potentially incompetent: In this case lip size is normal, but the lips fail to make a lipseal in a relaxed muscular state due to protruding upper central incisors.

Lymph node examination:

The lymph node examination is an important component of the extraoral examination. Lymph nodes should be examined for their number, location, temperature of the overlying skin, surface, margins and consistency. The lymph node involvement not only gives us the idea as to which group of lymph nodes is involved, but also helps us in making the diagnosis. Lymph node enlargement can be

Inflammatory: Caused by infection (Examples: Acute lymphadenitis, chronic lymphadenitis, tuberculosis, syphilis etc.)

Neoplastic: Caused due to neoplasms [primary (lymphosarcoma) or secondary (carcinoma, sarcoma, malignant melanoma)].

Hematological: Caused due to hematological disorders (Examples: Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, chronic lymphatic leukemia etc.).

Immunological: Caused due to immunological disorders (Examples: serum sickness, systemic lupus erythematosus, rheumatoid arthritis etc.).

Normally, lymph nodes are difficult to palpate, however, in an active infection, the lymph nodes draining that area become tender with overlying skin warm. The generalized or localized lymph node involvement should be identified because some diseases such as Hodgkin’s lymphoma or lymphosarcoma have generalized lymph node enlargement whereas localized infections have regional lymph node enlargement. In the absence of any local infection, an enlarging group of lymph nodes indicates systemic disease.

The lymphatic drainage of head and neck region consists of the following group of lymph nodes (Figure 39.2),

Deep cervical lymph nodes

The outer circle of lymph nodes

The inner circle of lymph nodes

Figure 39.2 Lymph nodes of head and neck

Lymph Nodes of Head and Neck

Deep cervical lymph nodes:

These lymph nodes surround the whole length of internal jugular vein and drain lymph from whole of the head and neck region. Most of the lymph reaching these nodes is already filtered by nodes of the outer and inner circle of lymph nodes. These lymph nodes are arranged into upper and lower group of lymph nodes. The upper group of lymph nodes is situated in the angle between the lower border of the mandible and anterior border of sternomastoid (Figure 39.3 a). Lymph nodes associated with the posterior belly of digastrics are called as jugulo-digastric lymph nodes.

The lower group of lymph nodes is situated in the angle between the sternomastoid and the clavicle. Lymph nodes present deep to sternomastoid and above the inferior belly of omohyoid are called as jugulu-omohyoid lymph nodes. The supraclavicular lymph nodes lie posterior to sternomastoid above the clavicle (Figure 39.3 b).

 Figure 39.3 a Posterior Cervical Lymph nodes examination

Posterior Cervical Lymph nodes

 Figure 39.3 b Supraclavicular lymph nodes examination

Supraclavicular lymph nodes examination

Outer circle of lymph nodes:

The outer circle of lymph nodes consists of submental lymph nodes, submandibular lymph nodes, buccal lymph nodes, mandibular lymph nodes, pre-auricular (parotid) lymph nodes, retro-auricular (mastoid) lymph nodes and occipital lymph nodes.

Submental lymph nodes:

These lymph nodes lie beneath the chin (Figure 39.4 a). These drain the tip of the tongue, floor of the mouth, gingiva surrounding the lower incisors and a part of the lower lip. These provide bilateral drainage of lymph and drain into a submandibular group of lymph nodes, but a few also drain into jugulo-omohyoid lymph nodes.

Submandibular lymph nodes:

These lie on the surface of the submandibular salivary gland (Figure 39.4 b). These drain from the submental lymph nodes, anterior 2/3rd of the tongue except the tip, the floor of the mouth, anterior half of the nose and sinuses (frontal, maxillary and middle & anterior ethmoidal sinuses). These drain into jugulo-digastric lymph nodes and few into jugulo-omohyoid lymph nodes.

Figure 39.4 a,b Sub-mental and Sub-mandibular Lymph Nodes Examination

Submental and Sub-mandibular Lymph Nodes

Buccal lymph nodes:

These lie on the surface of buccinators muscle.  These are small in size and drain the surrounding area.

Mandibular lymph nodes:

These lie on the lower border of the mandible at the anterior border of the masseter. These drain a part of the cheek and lower eyelids. These drain into the upper deep cervical lymph nodes.

Pre-auricular (parotid) lymph nodes:

These lie on or within the parotid gland (Figure 39.5 a). Drain the vertex, temple, eyelids, orbits and external acoustic meatus. These drain into upper deep cervical lymph nodes.

Retro-auricular (mastoid) lymph nodes:

These drain the scalp, auricle and external auditory meatus (Figure 39.5 b).

Pre-auricular and Post-auricular Lymph nodes examination

Pre-auricular and Post-auricular Lymph Nodes

Occipital lymph nodes:

These lie at the apex of the posterior triangle and drain the posterior part of the scalp (Figure 39.5 c). Drainage from these lymph nodes occurs into the lower deep cervical lymph nodes.

Occipital Lymph nodes examination

Occipital Lymph nodes

Inner circle of lymph nodes:

These lymph nodes surround the larynx, trachea, and pharynx. In this circle, we have pre-tracheal and paratracheal lymph nodes, which drain the lower larynx, trachea, and isthmus of the thyroid gland. The retropharyngeal lymph nodes drain the soft palate, posterior part of the hard palate, nose, and pharynx. All these lymph nodes drain into the deep cervical lymph nodes.

Figure 39.6 The Waldeyer’s ring

Waldeyer's ring

There is an important discontinuous ring of lymphatic tissues around the entrance of the mouth known as the Waldeyer’s ring (Figure 39.6). This ring is made up of the tonsils, which include,

Paired:

  • Palatine tonsils.
  • Tubal tonsils.

Unpaired:

  • Pharyngeal tonsil.
  • Lingual tonsil.

Waldeyer’s ring tissue serves as a defense against infection and plays an important role in the development of the immune system, comprising the first organs in the lymphatic system that analyze and react to airborne and alimentary antigenic stimulation.

The palpation of the lymph nodes in the orofacial and neck region is usually started with the most superior nodes and continuing downwards to the supraclavicular lymph nodes. The lymph node groups around the oral cavity are palpated starting with the submental lymph nodes and going posteriorly towards pre-auricular, post-auricular and occipital lymph nodes.

Examination of temporomandibular joint:

The temporomandibular joint (TMJ) is the articulation of the mandibular condyle with the glenoid fossa of the temporal bone. In TMJ there are two distinct movements, rotation and translation, occur in the joint during mandibular opening and closing. The TMJ, therefore, is called a ginglymodiarthroidal joint.

The pain in the orofacial region originating from………………..

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Clinical examination:

In the clinical examination of the TMJ, functions of the joint are evaluated by palpation and auscultation of the joint. In brief, noise in the joint during function is highly suggestive of the intraarticular disease. A grinding or crepitus often indicates an arthritic or other degenerative process and is caused by contact of roughened bony surfaces during the function. Clicking or popping in the joint is usually associated with displacement of the fibrocartilaginous disc (meniscus) that separates the joint into upper and lower compartments.

Lateral and posterior palpation of the joint:

In the lateral palpation, the examiner palpates the lateral pole of the condyle with the index finger or two fingers placed near the tragus of the ear (Figure 39.7 a). The patient is asked to slowly open and then close the mouth. The test is positive if pain is present. In posterior palpation, the examiner palpates the posterior portion of the condyle with the little finger in the patient’s ear (Figure 39.7 b). The patient is asked to slowly open and then close the mouth. The test is positive if pain is present. Popping or clicking of the joint can also be felt in many cases, if it is present.

Lateral and Posterior palpation of TMJ

Lateral and Posterior palpation of TMJ

Auscultation of the joint:

In this test stethoscope is placed on the lateral aspect of the joint and any sound during joint movement is recorded (Figure 39.7 c). Auscultation with a stethoscope is considered positive if the clicking sound is observed at least 4 times during 5 repetitions of mouth opening.

Auscultation of TMJ and mouth opening

Auscultation of TMJ and mouth opening

Deviation during movement:

The examiner stands in front of the patient and the patient is asked to slowly open the mouth widely without causing any pain. Normally, in an adult, the maximum mouth opening ranges from 35-50 mm (Figure 39.8 a). During opening if the mandible deviates to one side, it indicates disequilibrium between right and left TMJ.

Lateral and protrusive/retrusive movement of the joint:

In lateral movement, the patient is asked to slowly move the mandible to the right and then to the left side to the maximum without causing any pain (Figure 39.8 b). The movement should be similar on both sides. The normal lateral movement of the mandible is usually 8-10 mm. Reduced or abnormal movement on one side indicates a TMJ problem. Pain during the movement also indicates a TMJ problem. In protrusive/retrusive movements, the patient is asked to bring the mandible forward and then take it backward as much as possible without causing any pain (Figure 39.8 c).  Any abnormality or pain during the movement is recorded. These movements can also be done by the examiner by asking the patient to keep the mandible relaxed and then manually doing the movement by making the head stable with one hand and moving the mandible with the other hand.

Lateral movements of mandible

Lateral movements of mandible

Protrusive and retrusive movements of mandible

Protrusive and retrusive movements of mandible

Intra-oral examination

Hard tissue examination:

In the hard tissue examination, the teeth are examined. Before we record the dental and periodontal findings, we must follow a tooth notation system.

Tooth notation systems:

Following is a brief description of three most commonly followed tooth notation systems,

Palmer notation System

In 1861 Adolph Zsigmondy of Vienna introduced the symbolic system for permanent dentition. He then modified it for the primary dentition in 1874. The symbolic system is now commonly referred to as the Palmer notation system or Zsigmondy system (Figure 39.9 a).

Palmer notation System

Palmer notation System

Universal notation system:

ADA officially recommended the Universal system in 1968 . In this notation system for the permanent dentition, the maxillary teeth are numbered through 1 to 16 beginning with the upper right third molar. The mandibular teeth are numbered through 17 to 32 beginning with the lower left third molar. The universal system notation for primary dentition utilizes upper case alphabets (Figure 39.9 b).

Universal notation system

Universal notation system

The Federation Dentaire Internationale Numbering System (FDI):

The FDI system has been adapted by WHO and IADR. In this system, each quadrant is assigned a number. The maxillary right quadrant is assigned the number 1, the maxillary left quadrant is assigned the number 2, the mandibular left quadrant is assigned the number 3, and the mandibular right quadrant is assigned the number 4.The teeth within each quadrant are assigned a number from 1 through 8 with 1 being the central incisor and 8 being the third molar (Figure 39.9 c).

Federation Dentaire Internationale Numbering System (FDI)

Federation Dentaire Internationale Numbering System (FDI)

In the present case history discussion, we are following the FDI tooth notation system.

Type of Dentition:

Dentition of the patient may be deciduous/permanent/mixed. Type of dentition should be mentioned here.

Number of teeth present:

The total number of teeth present in the oral cavity are mentioned here.

Notation:

In the present case history discussion, we are following the FDI notation system. Although any system can be used, but the name of the notation system should be clearly mentioned.

Carious/Decayed:

All the teeth should be examined with the help of an explorer and carious teeth should be mentioned.

Missing:

The number of missing teeth, as well as the reason for their loss, should be mentioned because it gives us information about the type of dental diseases more prevalent in the patient under examination.

Filled:

Any kind of restoration should be examined and all the teeth with restorations should be mentioned here.

Stains and Deposits:

Patients with staining of teeth should be asked about any habit like tobacco chewing etc. Some patients regularly use chlorhexidine mouthwash. In these cases, although the patient may be having a good oral hygiene, but black stains on teeth because of chlorhexidine are usually seen. The deposits over and around the teeth indicate inadequate maintenance of oral hygiene by the patient.

Wasting Diseases:

Wasting diseases of the teeth is a broad term mainly used to describe the attrition, abrasion, erosion and abfraction of the teeth. In wasting diseases of the teeth, the enamel is worn off. If the disease is not controlled in its initial stage, it may involve the dentine and sometimes the whole tooth gets involved. The most systematic classification of tooth wasting diseases has been given by Grippo (2004) 9 who defined four categories of tooth wear:

  • Attrition: The loss of tooth substance as a result of tooth to tooth contact during normal or parafunctional masticatory
  • Abrasion: The pathological wear of tooth substance due to bio-mechanical frictional processes, e.g., tooth brushing (Figure 39.10).
  • Erosion: The loss of tooth substance due to dissolution by acid of either an intrinsic or extrinsic origin, e.g., gastric acid or dietary acids (Figure 39.11).

Figure  39.10  Loss  of  tooth  structure  due  to  faulty  brushing  technique

Abrasion

Figure 39.11 Erosion of the tooth structure because of excessive intake of carbonated soft drinks

Erosion

  • Abfraction: the pathological loss of tooth substance caused by biomechanical loading forces. It was postulated that these lesions were caused by flexure of the tooth during loading, leading to fatigue of the enamel and dentine at a location away from the point of loading. The word “abfraction’’ was derived from the Latin word, meaning ‘‘to break away’’. Grippo further described five categories of abfraction: hairline cracks, striations (horizontal bands of enamel breakdown), saucer-shaped (a lesion entirely within enamel), semi-lunar-shaped (a crescent-shaped lesion entirely within enamel), and cusp tip invagination (a depression on the cusp tip seen in molar and premolar teeth).
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Classification of tooth staining:
The tooth stains can be classified into three classes as extrinsic, intrinsic and internalized stains. The intrinsic staining occurs due to changes in structural composition or thickness of the dental hard tissues. Extrinsic staining occurs on the outside of the tooth substance and lies on the tooth surface or in the acquired pellicle. Internalized staining occurs due to the incorporation of extrinsic stain within the tooth substance.

Causes of intrinsic stains:
Tetracycline staining, alkaptonuria, congenital erythropoietic porphyria, congenital hyperbilirubinemia, amelogenesis imperfecta, dentinogenesis imperfecta, enamel hypoplasia, pulpal hemorrhagic products, root resorption and aging.

Causes of extrinsic stains:

Metallic stains (due to occupational exposure to metallic salts or due to intake of medicines containing metal salts) or non-metallic stains (dietary components, beverages, tobacco, mouth rinses and other medicaments) stains.

Causes of internalized stains:

Due to internalization of stains though enamel defects (developmental defects) and in the porous surface of exposed dentine (tooth wear, gingival recession, dental caries and restorative materials).

Occlusion class:

Class of Angle’s malocclusion should be mentioned here.

Food impaction:

Food impaction is the forceful wedging of food into the periodontium. There are two types of food impaction,

Vertical food impaction: It occurs due to,

  1. Open contacts
  2. Irregular marginal ridge
  3. Plunger cusps: Cusps that tend to forcibly wedge the food interproximally. Causes for plunger cusp formation include occlusal wear or a shift in tooth position

Horizontal (lateral) food impaction: It is seen mostly in areas with enlarged gingival embrasures due to gingival inflammation. Because of the inflammation, the embrasure is enlarged and lateral pressure from lips, cheeks, and tongue causes lateral food impaction.

Classification of factors causing food impaction: (Hirschfeld 1930) 10

Class I: Occlusal wear

Class II: Loss of proximal contact

Class III: Extrusion beyond the occlusal plane

Class IV: Congenital morphological abnormality

Class V: Improperly constructed restorations

Signs and symptoms of food impaction include:

  1. Discomfort/feeling of pressure
  2. Vague pain
  3. Root caries

Periodontal findings of food impaction may include:

  1. Gingival inflammation-bleeding and foul smell.
  2. Gingival recession
  3. Periodontitis
  4. Periodontal abscess formation
  5. Alveolar bone loss-vertical

Proximal Contacts:

Normal proximal contacts do not allow any food impaction in between the teeth. Open contact areas are usually associated with food impaction and gingival inflammation. Open contact areas can be found commonly in malaligned teeth or in the case of proximal caries where contact has been lost due to tooth decay.

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Pathological tooth migration:

Pathological tooth migration is tooth displacement that results when the balance among factors that maintain physiologic tooth position is disturbed by periodontal disease 11. It may present as extrusion, facial flaring, rotation, diastema, and the drifting of affected teeth, but most patients with pathological tooth migration appear to have combined forms with the most common being facial flaring and diastema. The position of a tooth depends on the health of the periodontium as well as other factors such as occlusion, oral habits and pressure from lips, cheeks and tongue.

Posterior bite collapse is one of the reasons for…………..

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Soft tissue examination:

Examination of oral mucosa and other structures:

Any abnormality associated with tongue, lips, buccal mucosa, floor of the mouth, frenum, soft palate, hard palate and vestibule should be noted.

Examination of the gingiva:

In the examination of gingiva, the gingival color, contour, consistency, surface texture, size, position (recession), gingival exudate, bleeding on probing, embrasures, McCall’s Festoons and Stillman’s Cleft are investigated.

Normal gingava

Gingiva

Color:

During gingival examination, first of all, color of the gingiva should be noted. The color of “clinically normal” or “clinically healthy” gingiva has a shade of pale or coral pink varied by complexion and pigmentation. In the case of chronic periodontitis, the inflamed gingiva may appear reddish pink/bluish in color, whereas in case of acute inflammation it may appear bright red in color. In mouth breathers, the part of gingiva which is exposed to air is often inflammed due to drying (Figure 39.12).

Figure 39.12 Gingivitis caused due to mouth breathing

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Contour: 

A healthy gingiva has knife-edged gingival margins that adapt closely around the tooth. The papilla is pointed and pyramidal in shape, filling the interproximal area between the teeth. If there is space between the teeth, the gingiva is flat or saddle-shaped with normal color. In inflammation, the gingival margins become rounded due to edematous and fibrotic changes and papillae become bulbous, flattened and blunted.

Consistency:

A healthy gingiva is firm and resilient. It can be checked by palpating the gingiva with the side of a blunt instrument (probe). During gingival inflammation, soft, spongy gingiva dents readily when gently pressed with the side of the probe. In chronic inflammation due to fibrotic changes in the gingiva, it is firm and hard. In this case, the gingival tissue may appear pink and well stippled but when probed bleeding usually occurs in pockets. It is important to note here that the gingival margin in healthy gingiva is closely adapted to the tooth surface. When the marginal gingiva can easily be displaced from the tooth surface with a light air blast, it indicates the destruction of gingival fibers that support the gingival margin.

Surface texture:

Healthy gingiva has a stippled appearance. It is usually known as the “orange-peel appearance” (Figure 39.13). Stippling is a consequence of the microscopic elevations and depressions on the surface of the gingival tissue due to the connective tissue projections within the tissue 12-14. Clinically, it can be seen by drying the gingiva with the help of cotton and viewing it under broad daylight. It is difficult to see it under a focused light such as that of the dental chair because light from all directions is required to see the elevations and depressions on the gingival surface clearly. Stippling is absent in infancy, appears in some children at about 5 years of age, increases until adulthood, and frequently begins to disappear in old age.

Figure 39.13 Stippling visible in the interdental gingiva.

Stippling

Size:

During gingival examination, size of the gingiva should be checked. Gingival enlargement is a common finding in many patients. There are many reasons for gingival enlargement which include inflammatory, fibrotic (drug-induced and idiopathic), combined, conditioned, genetic and neoplastic gingival enlargements. The detailed description of gingival enlargement has been given in chapter 25 “Gingival enlargement”.

Let us discuss how to record gingival enlargement. There are various indices which have been given to record gingival enlargement. Table 39.3 describes the Ingles index which is  commonly used indices to record increased gingival size.

Table 39.3 Ingles index for drug-induced gingival enlargement (1999) 15

Grade 0
1. No overgrowth; firm adaptation of the attached gingiva to the underlying alveolar bone.
2. There is slight stippling; there is no granular appearance or a slightly granular appearance.
3. A knife-edged papilla is present toward the occlusal surface.
4. There is no increase in density or size of the gingiva.
Grade 1
1. Early overgrowth, as evidenced by an increase in density of the gingiva with marked stippling and granular appearance.
2. The tip of the papilla is rounded.
3. The probing depth is less than or equal to 3 mm.
Grade 2
1. Moderate overgrowth, manifested by an increase in the size of the papilla and/or rolled gingival margins.
2. The contour of the gingival margin is still concave or straight.
3. Gingival enlargement has a buccolingual dimension of up to 2 mm, measured from the tip of the papilla outward.
4. The probing depth is equal to or less than 6 mm.
5. The papilla is somewhat retractable.
Grade 3
1. Marked overgrowth, represented by the encroachment of the gingiva onto the clinical crown.
2. The contour of the gingival margin is convex rather than concave.
3. Gingival enlargement has a buccolingual dimension of approximately 3 mm or more, measured from the tip of the papilla outward.
4. The probing depth is greater than 6 mm.
5. The papilla is clearly retractable.
Grade 4
1. Severe overgrowth, characterized by a profound thickening of the gingiva.
2. A large percentage of the clinical crown is covered.
3. Same as for grade 3: The papilla is retractable, the probing depth is greater than 6 mm, and the buccolingual dimension is approximately 3 mm.

Position:

Normally, the position of the gingiva is at cementoenamel junction (CEJ). Apical migration of gingiva from the CEJ is known as the recession. It must not be confused with loss of attachment. Whenever recession is present there is always a loss of attachment but the loss of attachment can also be there in the absence of recession in the form of true periodontal pockets.

Gingival exudate:

Any discharge from the gingival sulcus indicates disease activity going on in the periodontal pocket. It can be demonstrated by putting slight pressure on the lateral surface of gingiva. White purulent material oozing from the gingival margin indicates the presence of gingival exudate.

 Bleeding on probing:

Bleeding on probing is an indicator of tissue inflammatory response to bacterial pathogens. It is the first sign of gingivitis. In the absence of the normal signs of inflammation, the gingiva may not be free of inflammation. So, bleeding on probing is an important sign of gingivitis. In chronic inflammation, the gingiva may appear fibrotic but inflammation is actively present in the gingival sulcus and junctional epithelium. It is important to note here that in smokers, bleeding on probing may be reduced due to the effects of nicotine. In acute inflammation, the bleeding may occur even after a slight provocation, such as a short burst of compressed air.

 Embrasures:

Gingival embrasures are defined as the embrasure cervical to the interproximal contact 16. The interdental papilla fills the space up to tooth contact in normal conditions. However, due to periodontal disease, there is a loss of interdental soft tissue and bone levels. Due to this, the position of the interdental papilla recedes from its normal position. Nordland and Tarnow (1998) 17 have given a classification of interdental papillary height as follows,

Normal: The interdental papilla occupies the entire embrasure space apical to the interdental contact point /area.

Class I: The tip of the interdental papilla is located between the interdental contact point and the level of the CEJ on the proximal surface of the tooth.

Class II: The tip of the interdental papilla is located at or apical to the level of the CEJ on the proximal surface of the tooth but coronal to the level of the CEJ mid-buccally.

Class III: The tip of the interdental papilla is located at or apical to the level of CEJ mid-buccally.

Various interdental aids used to clean different types of embrassures have been discussed in chapter 45 “Mechanical plaque control”.

McCall’s Festoons:

These are life preserver-shaped rolled margins of gingiva (Figure 39.14) where the gingiva shows fibrotic properties.

Photograph showing McCall’s Festoon 

McCall's Festoon

Stillman’s Cleft:

Sometimes, the first sign of recession is the formation of a small groove in the gingiva. This cleft-like recession is known as Stillman’s cleft.

Periodontal examination:

After the gingival examination is over, we record the periodontal findings. These include recording of periodontal pocket depth and loss of attachment, furcation involvement, mobility, pulpo-periodontal findings, occlusal findings and mucogingival findings. Periodontal examination is done in a systematic way, examining all surfaces of every tooth and recording the findings in a periodontal chart. Figure 39.15 demonstrates the quadrant from where we start the periodontal examination, the chair side position  and how to go ahead with recording each and every surface of the tooth systematically.

 Before we go into details of periodontal findings lets first try to understand how periodontal pockets and clinical attachment loss is recorded (Figure 39.16).

Systematic  Periodontal examination

Systematic  Periodontal examination

Pocket depth:

The distance between gingival margin and the base of the pocket is known as pocket depth. The pocket depth determination is the cornerstone of periodontal examination. A correct probing technique is essential to accurately determine the pocket depth. One should know the exact probing technique to avoid any false readings during the periodontal examination.

Probing technique:

Probing is the act of walking the tip of a probe along the junctional epithelium within the sulcus or pocket for the purpose of assessing the health status of the periodontal tissues. A graduated periodontal probe is inserted into the periodontal pocket till it is stopped by resistance due to junctional epithelial attachment.

Walking of periodontal probe:

The walking stroke is the movement of a calibrated probe around the perimeter of the base of a sulcus or pocket. A calibrated probe is walked around the circumference of the tooth (Figure 39.17). The purpose is to record the periodontal pocket depth around the tooth surface. It is important to note that the junctional epithelial attachment is not uniform around the tooth surface.  The periodontal pocket may be present only on one surface of the tooth.

Walking of the periodontal probe

Walking of the periodontal probe

Procedure of walking the probe:

The probe is kept against the tooth surface and is inserted into the sulcus/pocket. The probe tip (1-2 mm of probe tip) is kept in contact with the tooth surface. The probe should be kept as parallel as possible to the mesiodistal and faciolingual dimension of the tooth. A series of bobbing strokes are made within the sulcus or pocket. Clinically, the force applied to the periodontal probe can be measured as the force equivalent to cause blanching of the nail bed. The probe is inserted until the tip encounters the resistance of the junctional epithelium that forms the base of the sulcus. Short, up and down, and incremental strokes of 1mm are made by moving the probe along the tooth surface.  The probe should not be removed from the sulcus while probing as repeated insertion of the probe into the periodontal pocket may traumatize the gingival margin. While walking the probe only the deepest reading on one tooth surface is recorded (Figure 39.18).

Recording of pocket depth

Recording of pocket depth

Probing the contact area:

It is done in two steps (Figure 39.19). Firstly, the probe is kept parallel to the long axis of the tooth with the tip of the probe touching the tooth surface. By walking the probe it is brought to the contact area of the teeth. The probe cannot go beyond this point into the contact area. In the second step, the probe is slightly tilted so that the tip reaches under the contact area. Now, with the probe in its right position, recommended force is applied and recording is taken when the probe touches the junctional epithelium below the contact area.

Probing the contact area

Probing the contact area

How to probe maxillary molars:

Because of the angulation of the probe, it is difficult to probe the maxillary molars especially the distal surface. Mandibular teeth also come in the way of placing a periodontal probe. So, in this case, the cheek of the patient can be retracted and the probe can be repositioned to the side of the patient’s face. Then, by following the above stated procedures, the deepest probing depth should be noted on each surface of the tooth.

Clinical attachment loss:

For calculating the clinical loss of attachment, we need to first find out the location of the CEJ because clinical attachment loss is the apical migration of junctional epithelium from its normal position at CEJ. If the cervical area of the tooth is covered by calculus, it is difficult to find out the exact location of the CEJ. So, in such case, first the calculus should be removed by scaling. Then a periodontal probe is moved on the enamel of the tooth over the crown surface guiding it onto the root surface. We can feel the change in tactile sensation when the tip of the probe reaches the CEJ.  The probe is further moved towards the apical portion of the tooth till it faces resistance from the junctional epithelial attachment.  The distance between the CEJ and the base of the pocket is the clinical loss of attachment. Figure 39.20 demonstrates a sample chart for recording periodontal pocket depth and attachment loss.

Measurement of periodontal pocket depth and clinical attachment loss

Measurement of attachment loss

Following chart is the basic format for recording the periodontal findings although it may be modified accordingly.

Periodontal Chart

Periodontal Chart

Tooth mobility:

The AAP definition of tooth mobility is “The movement of a tooth in its socket resulting from an applied force”. Normally, all healthy teeth have some physiological tooth mobility which varies for different teeth and at different times of the day. It is greatest on arising in the morning and progressively decreases during the day. The increased mobility in the morning is attributed to slight extrusion of the tooth because of limited occlusal contact during sleep. During the waking hours, mobility is reduced by chewing and swallowing forces, which intrude the teeth in the sockets 18.  Tooth mobility is graded clinically by applying firm pressure with either two metal instruments or one metal instrument and a gloved finger. Various mechanical or electronic devices for the precise measurement of tooth mobility have also been designed. The Muhlemann’s Periodontometer and Periotest are examples of such devices.

Classification of tooth mobility

Miller Classification 18
Class 0
Normal (physiologic) movement when force is applied.
Class I
Mobility greater than physiologic.
Class II
The tooth can be moved up to 1mm or more in a lateral direction (buccolingual or mesiodistal). Inability to depress the tooth in a vertical direction (apicocoronal).
Class III
The tooth can be moved 1mm or more in a lateral direction (buccolingual or mesiodistal). Ability to depress the tooth in a vertical direction (apicocoronal).
Glickman grading of tooth mobility 11
Normal
Grade 1
Slightly more than normal
Grade 2
Moderately more than normal
Grade 3
Severe mobility faciolingually and /mesiodistally combined with vertical displacement.

 

Furcation involvement:

The extension of inflammatory periodontal disease into the inter-radicular area of multirooted teeth is known as furcation involvement 19. Diagnosis of furcation involvement is based on probing and radiographic findings. Nabers No. I and No. 2 probes have been designed especially for clinical detection of furcation involvement. To detect furcation involvement, the tip of the probe is moved towards the presumed location of the furcation and then curved into the furcation area. Mandibular molar furcation is easy to detect because they usually has two roots. Detection of furcation involvement in maxillary molars (especially the mesial and distal furcation) is difficult as compared to mandibular molars. For the mesial surfaces of maxillary molars, it is better to go for a palatal direction, as the mesial furcation is located palatal to the midpoint on the mesial surface. The distal furcation of maxillary molars is located more towards the midline, and may be detected by a buccal or palatal approach.

Although various classifications of furcation involvement have been proposed, following are commonly used classifications for furcation involvement,

Classifications of furcation involvement

According to Glickman (1953) 20
Grade I: It is the incipient stage of furcation involvement, but radiographically changes are not usually found.
Grade II: The furcation lesion is a cul-de-sac with a definite horizontal component. Radiographs may or may not depict the furcation involvement.
Grade III: The bone is not attached to the dome of the furcation. Grade III furcations display the defect as a radiolucent area in the crotch of the tooth.
Grade IV: The interdental bone is destroyed and soft tissue has receded apically so that the furcation opening is clinically visible.
According to Hamp et al. (1975) 21
Degree I: Horizontal loss of periodontal support not exceeding 1/3rd of the width of the tooth.
Degree II: Horizontal loss of periodontal support exceeding 1 / 3rd of the width of the tooth.
Degree III: Horizontal through and through destruction of periodontal tissue in the furcation area.
According to Tarnow and Fletcher (1984) 22
Based on vertical component. Depending on the distance from the base of the defect to the roof of the furcation:
Subgroup A: Vertical destruction of bone up to 1 / 3rd of the inter-radicular height (1-3 mm).
Subgroup B: Vertical destruction of bone up to 2/3rd of the inter-radicular height (4-6 mm).
Subgroup C: Vertical destruction beyond the apical-third (7 mm or more).
More classifications have been given in “Furcation involvement and its treatment”.

Tender on percussion:

Any tooth which is tender on vertical or lateral percussion should be noted. Tenderness on vertical percussion indicates periapical involvement whereas tenderness on lateral percussion indicates periodontal involvement.

Periodontal abscess:

If periodontal abscess is present, it should be evaluated for the involved tooth. Periodontal abscess may be purely of periodontal origin or may be a combined abscess due to periodontal-endodontic involvement. The treatment plan is formulated accordingly.

Mucogingival findings:

The mucogingival findings include recession, depth of the vestibule and width of attached gingiva.

Recession:

The recession has already been discussed under the heading of gingival findings and subheading position of the gingiva. The apical migration of the gingival margin from its normal position at the CEJ is known as recession. In the periodontal examination chart, the Class of recession is mentioned with the respective tooth. Following are the two main classifications of recession out of which Miller’s classification of recession is most commonly used.

Classification of recession

According to Miller 23
Class I: Marginal tissue recession not extending to the mucogingival junction. No loss of interdental bone/soft tissue.
Class II: Marginal tissue recession extends to or beyond the mucogingival junction. No loss of interdental bone/soft tissue.
Class III: Marginal tissue recession extends to or beyond the mucogingival junction. Loss of interdental bone / soft tissue or there is malpositioning of the tooth.
Class IV: Marginal tissue recession extends beyond the mucogingival junction. Loss of interdental bone and soft tissue loss interdentally and/or severe tooth malposition.
According to Sullivan and Atkins
• Shallow-narrow
• Shallow-wide
• Deep-narrow
• Deep-wide

 

Depth of the vestibule:

The depth of the vestibule may be adequate or inadequate.  It is related to the width of attached gingiva. If the width of the attached gingiva is normal the vestibular depth is usually adequate. When the attached gingiva is minimal the vestibule is also shallow. Tension test is used to check the adequacy of attached gingiva.

Tension test:

This test is performed to check the adequacy of attached gingiva as well as an abnormal frenal attachment. Here the lip is moved outwards, upwards for the upper and downwards for the lower lip and also moved sideward. If the marginal and/or the interdental papilla moves away from the tooth surface, then the tension test is said to be positive. A positive tension test indicates the minimal width of attached gingiva for which mucogingival surgical procedures for increasing the width of attached gingiva are indicated. However, it has been shown that if the patient has good oral hygiene maintenance, a minimal width of attached gingiva can be maintained without a progressive recession.

Width of attached gingiva:

Attached gingiva is non-movable gingiva, as the name indicates. It is lined by keratinized stratified squamous epithelium. The width of attached gingiva is generally greatest in the incisor region (3.5 to 4.5 mm in the maxilla and 3.3 to 3.9 mm in the mandible) and less in the posterior segments, with the least width in the first premolar area (1.9 mm in the maxilla and 1.8 mm in the mandible).

 

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Identification of width of attached gingiva:

For the identification of the width of attached gingiva, two landmarks should be identified: sulcus/pocket depth and mucogingival junction.

Measurement approach:

In this method first the pocket depth or the sulcus depth is measured, and then the total width of gingiva is measured, i.e., from the gingival margin to the mucogingival line. Subtracting the two measurements gives us the width of attached gingiva. The mucogingival junction is identified by stretching the lip/cheek laterally outwards. By doing so junction of the immovable attached gingiva and movable alveolar mucosa can be identified (Tension test). It can also be identified by rolling the alveolar mucosa over the attached gingiva with a blunt instrument (Roll test). Here, the movable alveolar mucosa accumulates ahead of the instrument till the mucogingival junction, when pushed coronally.

Histochemical method:

Histochemically, iodine solution can be used to identify the width of attached gingiva. Schiller’s or Lugol’s solution (iodine and potassium iodide solution) is painted on the gingiva and oral mucosa. Because of the glycogen content of alveolar mucosa, it takes on a brown color, while the glycogen free, attached gingiva remains unstained. The total width of the unstained gingiva is measured and the sulcus/pocket depth is subtracted from it to determine the width of attached gingiva.

 

 

Examination of occlusion:

Occlusal findings:

The occlusion of the patient should be thoroughly examined.  Abnormal forces from the opposing teeth may cause various signs and symptoms ranging from slight discomfort to severe pain. Occlusal disharmony is usually a result of traumatic occlusion/ trauma from occlusion.

Fremitus test:

This test is used to detect trauma from occlusion. In this test vibratory pattern of the teeth is observed when they are brought in contact. This test has been described in chapter 35 “Trauma from occlusion”.

Wax records:

The wax records should be obtained if occlusal interferences are identified. Wax records are used to replicate patient’s occlusion on articulator. The interferences are first corrected on the articulator and are then replicated on the patient. For details, read chapter 34 “Temporomandibular joint and occlusal considerations in periodontics”.

Radiographic findings:

The radiographic analysis is required to know the extent of periodontal destruction in the form of bone loss. Intraoral periapical radiographs or orthopantomogram are normally used to do the radiographical analysis. In the radiographical analysis, we record the amount of bone remaining with respect to tooth under examination, bone density, continuity of lamina dura, any radiolucent areas, pattern of bone loss and any other finding of significance. Table 39.4 describes the commonly used method of recording radiographic findings by dividing entire dentition into six saxtants.

Table 39.4   Sample chart for recording the radiographic findings

Tooth region

Radiographic findings

18-14

 

13-23

 

24-28

 

38-34

 

33-43

 

44-48

 

Following periodontal chart shows how the gingival margin and clinical attachment levels are drawn systematically,

Recording the gingival margin and attachment level

Sample Periodontal Chart

 

Provisional diagnosis

A provisional diagnosis is the one that is initially determined to be the diagnosis. It is followed by investigations which help us in making the final diagnosis.  The special investigations may include microbiological, immunological or molecular investigations.

Special investigations:

Microbiological analysis:

It involves the isolation and identification of bacteria from plaque samples. Some bacteria can be grown in culture, whereas others may not be grown in cultures. The colony count of bacteria grown in culture gives us an indication regarding the number of bacteria in plaque sample. This investigation is important for the diagnosis of aggressive periodontitis cases and some special cases where repeated treatment is not able to control the disease progression.

DNA analysis to identify plaque microorganisms:

The DNA analysis is done for those bacteria which cannot be grown in culture. Here the plaque sample is subjected to various DNA amplification methods. The specific DNA of a bacterial species is allowed to pair with the DNA available in the sample. If that particular organism is present in the sample its DNA makes a double strand with the test DNA single strand which is then amplified for identification.

Immunological investigations:

These investigations are based on immunological tests. For example, patients with aggressive periodontitis have polymorphonuclear cell function abnormalities which predispose the patient for the rapid periodontal breakdown. These tests are used to confirm these abnormalities.

Blood examination:

It is done for patients scheduled for periodontal surgery as well as patients who are suspected to have any kind of bleeding disorder. The routine blood examination is mandatory before any surgical procedure. If the patient has any systemic disease the corresponding blood tests should be advised.

Urine examination:

Urine examination is indicated in patients with systemic diseases where the disease status can be identified by doing specific tests.

Biopsy:

In the case of any overgrowth, an excisional or incisional biopsy should be taken and sent for histopathological investigation.

Study casts:

Study casts are especially useful for occlusal evaluation of the patient. If the patient is having any kind of occlusal disharmony, these casts are articulated on a fully adjustable articulator and selective occlusal reduction is carried out to achieve occlusal harmony which is then replicated on the patient.

Any other specific test:

Any other specific test should be advised if required under special circumstances.

Final diagnosis

A complete and accurate diagnosis is required to make an appropriate treatment plan. The final diagnosis should include all the periodontal conditions for which the patient requires treatment. For example, a patient who has been diagnosed with generalized aggressive periodontitis also has secondary trauma from occlusion. So, the diagnosis should be “Generalized aggressive periodontitis with secondary trauma from occlusion with respect to (notation of teeth)”. Any systemic disease that affects the progression of periodontal disease should also be taken into consideration while making the final diagnosis.

Prognosis

The prognosis is a prediction of the probable course, duration, and outcome of a disease, based on the general knowledge of the pathogenesis of the disease and presence of risk factors for the disease. It can be of two types: overall prognosis and individual prognosis.

Overall prognosis:

It is the prognosis based on the sum of various local, systemic, environmental and other factors which may affect the overall periodontal health of teeth. Factors which affect the overall periodontal prognosis include age, genetics, oral hygiene, systemic conditions, smoking, patient compliance and economic consideration.

Individual prognosis:

It is the prognosis of individual teeth, based on local and prosthetic/restorative factors that have a direct effect on their prognosis. These factors like attachment loss, probing depth, furcation involvement; crown-to-root ratio, fixed abutment status, and percentage of bone loss are the most important factors in determining tooth loss. A detailed description of prognosis is available in  “Determination of prognosis”.

Treatment plan

The treatment plan is the reflection of diagnosis. An accurate and complete diagnosis guides us to formulate an appropriate treatment plan. For a systematic approach, treatment plan has been divided into four phases (Table 39.5).

Phase I Therapy or Etiotropic Phase

Phase II Therapy or Surgical Phase

Phase III Therapy or Restorative Phase

Phase IV Therapy or Maintenance Phase or supportive periodontal therapy

If the patient is in pain these phases are preceded by the emergency phase, which involves the elimination of pain or any other emergency treatment. It is important to note that after completion of Phase I therapy, the patient is placed on the Maintenance Phase (Phase IV) to preserve the results obtained and prevent any further deterioration and recurrence of the disease. During this period when the patient is in the maintenance phase, Phase II therapy or Surgical Phase and Phase III Therapy or Restorative Phase is carried out.

Table 39.5 Phases of treatment plan

Emergency phase/Preliminary Phase
• Due to endodontic or periapical pathology
• Due to periodontal pathology
• Any other reason
• Extraction of hopeless teeth and provisional replacement if required.
Phase I Therapy or Etiotropic Phase
• Patient education about plaque control and maintaining oral hygiene. Demonstration of accurate brushing technique indicated for patient.
• Scaling and root planing to remove soft deposits and calculus
• Restorative and/or prosthetic corrections
• Excavation of caries and restoration (temporary or final, depending on whether a definitive prognosis for the tooth has been arrived at and on the location of caries)
• Antimicrobial therapy (local drug delivery or systemic)
• Diet control (in patients with rampant caries)
• Treatment of occlusal abnormalities
• Minor orthodontic movement
• Provisional splinting and prosthesis
Evaluation of Response to Etiotropic Phase
• Pocket depth and gingival inflammation
Phase II Therapy or Surgical Phase
• Periodontal surgical procedures including placement of implants.
• Endodontic therapy completion
Phase III Therapy or Restorative Phase
• Final restorations
• Fixed and/or removable prosthodontics
Phase IV Therapy or Maintenance Phase or supportive periodontal therapy for Periodic rechecking
• Plaque and calculus evaluation
• Gingival and periodontal status
• Occlusion, tooth mobility
• Any other pathologic changes

Supportive periodontal therapy

Maintenance phase or supportive periodontal therapy is defined as an extension of active periodontal therapy. It is distinct from but is an inseparable part of active periodontal treatment. During this phase of the treatment plan, the patient is periodically evaluated for the periodontal status and needful treatment is provided according to the disease condition. Details about supportive periodontal therapy are available in “Periodontal maintenance”. According to Merin’s classification (Table 39.6), the patient recall during the first year is different from the following years.

Table 39.6 Merin’s classification 11

First year following periodontal treatment
CharacteristicsRecall Interval
First yearFirst Year Patient: routine therapy and uneventful healing.3 months
First Year Patient: difficult case with complicated prosthesis, furcation involvement, poor crown-to-root ratios, or questionable patient cooperation.1-2 months
After first year following periodontal treatment
Class AExcellent results well maintained for 1 year or more. Patient display good oral hygiene, minimal calculus, no occlusal problems, no complicated prostheses, not remaining pockets, and no teeth with less than 50% of alveolar bone remaining.6 months to 1 year
Class BGenerally good results maintained reasonably well for 1 year or more, but patient displays some of the following factors:
1. Inconsistent or poor oral hygiene
2. Heavy calculus formation
3. Systemic disease that predisposes to periodontal breakdown
4. Some remaining pockets
5. Occlusal problems
6. Complicated prostheses
7. Ongoing orthodontic therapy
8. Recurrent dental caries
9. Some teeth with less than 50% of alveolar bone support
10. Smoking
11. Positive family history or genetic test
12. More than 20% of pockets bleed on probing.
3-4 months (decide on recall interval based on number and severity of negative factors)
Class CGenerally poor results after periodontal therapy and / or several negative factors from the following list:
1. Inconsistent or poor oral hygiene
2. Heavy calculus formation
3. Systemic disease that predisposes to periodontal breakdown
4. Many remaining pockets
5. Occlusal problems
6. Complicated prostheses
7. Recurrent dental caries
8. Periodontal surgery indicated but not performed for medical, psychological, or financial reasons
9. Many teeth with less than 50% of alveolar bone support
10. Condition too far advanced to be improved by periodontal surgery
11. Smoking
12. Positive family history or genetic test
13. More than 20% of pockets bleed on probing
1-3 months (decide on recall interval based on number & severity of negative factors; consider retreating some areas or extracting severely involved teeth)

Conclusion

Case history recording is the first and most important steps in the successful outcome of the treatment. It is the blueprint of overall treatment planning for a patient. Further, case history also provides us the information regarding the risk factors associated with the disease progression in a particular patient. An appropriate treatment planning may prevent many complication that can happen intra-operatively and postoperatively . However, it must be remembered that a good history recording requires an in depth knowledge of the subject. One should master the art of history taking for appropriate treatment of the patient.

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Periobasics: A textbook of Periodontics and Implantology

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