The art of history taking in periodontology

It is better to know what kind of patient has the disease than what kind of disease the patient has.

Sir William Osler

Introduction:

Case history recording is the first and probably the most important step in treatment of the patient. A correct diagnosis leads us to a correct treatment plan. A good clinician starts examining the patient when he/she walks into the room. One of my teachers used to say “a good case history speaks the diagnosis itself”.  This statement seems absolutely correct, as a properly taken case history always leads us to a provisional diagnosis which is almost every time correct and coincide with the final diagnosis confirmed by special investigations.

Unfortunately, a detailed case history is sometimes ignored and only the chief complaint of the patient is considered by many clinicians. This should not be the case as many findings are ignored in this way. 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.

Biographic and demographic information:

This is the first step in history taking where we record patient’s name, address, and telephone number; identification number (eg, 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 patients name. It helps us to develop a personal bond with the patient and secondly, the patient feels that the doctor is not treating him like just another case. It also helps in eliciting case history as well as psychologically the patient is assured that doctor is giving him personal attention.

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 are usually old patients. Wasting diseases like attrition and abrasion are more common in elderly patients.

Gender:

Women are usually more proactive than men in maintaining their dental and periodontal health. Certain diseases are more common in a particular gender. For example, localized aggressive periodontitis with circumpubertal onset is usually more common in females as compared to males. Genetic polymorphisms are commonly associated with severe periodontal diseases which are also many times unequally expressed in males and females.

Osteoporosis is disease associated with decreased bone density. It is usually found in post menopausal women due to decrease of oestrogen levels in body. It is well established that estrogen maintains the bone mineral density and its decreased levels are associated with decrease in bone mineral density.

Religion:

Religion of the patient is important to know because………………………………………………123

So, 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 less visits to the dentist as well as lack of dental insurance.

Occupation:

Most important associated factor 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 everyday and are subjected to work overload. These patients usually have gingival inflammation which if ignored may lead to periodontitis. Another problem usually noticed is attrition of teeth. This has also become a common problem which has been associated with mental stress.

People working in chemical factories usually have tooth erosion associated with dentinal sensitivity.

Factory workers are usually habitual of taking tobacco in quid form which predisposes them for development of oral leukoplakia as well as oral cancer.

Sex-workers and people who frequently stay away from home are at more risk of having sexual transmitted diseases like AIDS. so, special care should be taken regarding disinfection and sterilization.

Occupation also affects the patients 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 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 are usually found in a particular area. It may be a village or even a part of city. For example fluoride levels in different drinking water sources may vary. It results in fluorosis in affected area where fluoride levels are more the optimum.

Malocclusions associated with skeletal involvement are common with certain populations. It has been seen that people who have origin from a particular race have peculiar dental and skeletal features. 

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 past the term “chief complaint” was used for a single problem as the patient used to see a dentist for a single illness. In the past 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 inability to eat due to missing teeth.

Another example is a patient complaining of bleeding gums and malaligned teeth. Both the problems have equal importance and are equally important to the patient, so both can be considered as chief complaints or active problems.

Procedure:

Ideally, open ended questions like “What brings your 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. Encourage them to be as descriptive as possible. Once the patient has described his problem in detail we can go ahead with our questions focused on finding out the complete detail of the problem.

Periodontology case history recording procedure

Periodontology case history record

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History of present illness:

A detailed description of the patient’s current problem developed chronologically is called the “history of present illness”. Every symptom and sign has 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. There is a set pattern of questions which must be asked in a sequential manner to identify 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 duration of the pain or problem. Simple question here is “when it started?” if the patient has come with swelling, its onset should be asked. A swelling is usually preceded by pain so everything should be recorded in chronological order.

Location: The patient should be asked to locate the pain. In enodontic problems the pain is usually sharp and patient can locate it easily pointing out the concerned tooth if periodontal ligament is involved along with the pulpal involvement. In case of periodontal problem the pain is usually dull and gnawing in nature deep in the bone which the patient can not 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 mandibular tooth is involved. It should be recorded.

Duration:  The question to be asked here is “How long has this condition lasted?”  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.

Reliving factors: Reliving factors of the pain should be recorded. In periodontal problem patient sometimes is relived of the pain by forcefully clenching 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 case of irreversible pulpitis the pain may stay for more 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 variable duration.

Past dental history:

The past dental history (PDH) is one of the most important components of the patient history. In this step we record……………………..

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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, patient presents with complicating dental and medical factors such as prosthetic or 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 is taking should be recorded. If the patient has undergone any radiation therapy it is important to find out date and nature of diagnosis; the type and anatomic location of treatment. In brief past medical history consists of following,

Major illnesses, beginning in childhood

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. 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.

Hospitalizations

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

Significant injuries

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

Medications

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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. Patient should be asked about 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 here is to note 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 1.

Immunizations

Immunization is a common procedure these days. Because of increased prevalence of transmissible diseases patients without immunization are at high risk of spreading a 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.

In trauma patients history of tetanus toxoid immunization should be taken because if the patient has been immunized within one year of trauma, there is no need of giving tetanus toxoid injection. In case where the patient has never been immunized for tetanus and high risk patients where wound is suspected to be contaminated anti-tetanus serum (ATS) should be given followed by tetanus toxoid.

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, 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 patient to any ionizing radiations.  Surgical treatments should be avoided during pregnancy. If necessary, should be carried out during second trimester of pregnancy. During pregnancy use medications only if absolutely indicated. Certain antibiotics (streptomycin, kanamycin, and tetracycline) are best avoided entirely in 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. Some of the antibiotics that may be prescribed safely during pregnancy include:

  • Amoxicillin
  • Ampicillin
  • Clindamycin
  • Erythromycin
  • Penicillin
  • Gentamicin
  • Ampicillin-Sulbactam
  • Cefoxitin
  • Cefotetan
  • Cefazolin

Postural hypotension in pregnant patients:

One major change in 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 2. It requires no treatment though.

In addition to this,………………………..

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Family History:

Gathering a complete and accurate family medical history is very important as 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 genetic basis of periodontal diseases. Along with this many systemic diseases like diabetes which affect the course of periodontal disease also have genetic factors involved. So, systematic inquiry into possible presence of disease states in the family that might affect patient’s dental and systemic health should be recorded. This would include information about:

  • Information about dental health of parents and reasons for loss of teeth.
  • Number of family members having similar periodontal condition.
  • Number of females and males in family exhibiting similar periodontal condition.

Personal history:

In addition to dental and medical histories, personal history should also be recorded. It includes details of the patient – their work, relationships, hobbies, beliefs- often develop over time – the days of a hospital stay or the years of a relationship in the office. In the short term, need to answer three questions: How does the patient’s lifestyle or personal traits:

Content:

  • Economical status can be judged by asking the patient his monthly or yearly income
  • Age, marital status, ethnicity, insurance status (can be important for ability to adhere to treatment plans).
  • Occupational history including description of work
  • Possible exposures (chemicals, sound, overuse injury, stress)
  • Education (Highest level completed).
  • Tobacco use Type, age at onset of use, frequency, intensity, if quit, when.
  • Alcohol use. Frequency, duration, amount, history of alcohol related problems.     
  • Illegal drug use. Type of drug, frequency and duration of use, how it is used (smoked, injected, etc.). These patients are at high risk of transmitting diseases.
  • Marital and other significant relationships/family composition
  • Sexual history

Oral hygiene measures:

Patient should be asked about the oral hygiene measures he is taking. It includes type of oral hygiene procedure used, frequency of brushing/flossing, type of brush used, technique of brushing the teeth, frequency of changing brush, other procedures like chemical plaque control and adjunctive aids like toothpick etc.

A sample case history record used for taking case history

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: 

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Clinical examination

 

Clinical examination starts with extra-oral examination. In this examination lymph Nodes, temporomandibular joint (TMJ), facial Symmetry and Lip competence are recorded.

Extra-oral examination:

Facial symmetry:

Although no face is bilaterally perfectly 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,

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

Various causes of facial asymmetry

Inflammatory

Developmental

Acquired

Congenital

Due to space abscess having endodontic/periodontic or combined origin Usually have unknown cause TMJ ankylosis Cleft lip and palate
Unilateral condylar hyperplasia Hemifacial microsomia
  Facial trauma Craniosynostosis
Childhood radiotherapy Tessier craniofacial cleft
  Fibrous dysplasia Craniosynostosis
Romberg’s disease Vascular disorders
Other Facial tumors 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 another cause of facial asymmetry.  TMJ ankylosis is followed by trauma to the joint. So, a history of fall or trauma to 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 competence:

Lip competence is a natural seal made between upper and lower lip without any effort at rest. Normally lips are closed but in some patients lips cannot make seal at rest which is a common condition in mouth breathers. Dryness of the gingiva exposed to the air leads the gingivitis known as mouth-breathers’ gingivitis.

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.

Potentially competent – In this case positioning of the upper incisors prevents a comfortable lip seal from being obtained.

Incompetent – Lips are incompetent when excessive muscular activity is required to produce a lip seal. Signs of excessive activity include puckering of the skin overlying the chin, due to mentalis contraction and flattening of the labiomental fold when the lips are held together.

Lymph node examination:

The lymphatic drainage of head and neck region consists of following group of lymph nodes

Deep cervical lymph nodes

The outer circle of lymph nodes

The inner circle of lymph nodes

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 head and neck region. Most of the lymph reaching these nodes is already filtered by nodes of 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 are situated in the angle between the lower border of the mandible and anterior border of sternomastoid. 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.

  Posterior Cervical Lymph nodes examination

Posterior Cervical Lymph nodes

Supraclavicular lymph nodes examination

Supraclavicular lymph nodes examination

The outer circle of lymph nodes:

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

Sub-mental lymph nodes:

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

Sub-mandibular lymph nodes:

These lie on the surface of sub-mandibular salivary gland. These drain from the sub-mental lymph nodes, anterior 2/3rd of tongue except tip, 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.

Sub-mental and Sub-mandibular Lymph Nodes Examination

Submental and Sub-mandibular Lymph Nodes

Buccal nodes:

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

Mandibular lymph nodes:

These lie on the lower border of the mandible at anterior border of masseter. These drain part of cheek and lower eye-lids. These drain into the superior deep cervical nodes.

Pre-auricular (parotid) lymph nodes:

These lie on or within the parotid gland. Drain the vertex, temple, eye-lids, orbits and external acoustic meatus. These drain into upper deep cervical lymph nodes.

Retro-auricular (mastoid)(post-auricular) lymph nodes:

These drain the scalp, auricle and external auditory meatus.

Pre-auricular and Post-auricular Lymph nodes examination

Pre-auricular and Post-auricular Lymph Nodes

Occipital lymph nodes:

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

Occipital Lymph nodes examination

Occipital Lymph nodes

The inner circle of lymph nodes:

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

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

Paired:

  • Palatine tonsils.
  • Tubal tonsils.

Unpaired:

  • Pharyngeal tonsil.
  • Lingual tonsil.

The Waldeyer’s ring

Waldeyer's ring

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 analyse and react to airborne and alimentary antigenic stimulation.

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 orofacial region originating from the area of the temporomandibular joint (TMJ) may be due to……………………………………………

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The detailed description of temporomandibular joint disorders has been given in “Temporomandibular joint disorders and their treatment”.

Clinical examination:

In the clinical examination of temporomandibular joint, the 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 intraarticular disease. A grinding or crepitus often indicates an arthritic or other degenerative process and is caused by contact of roughened bony surfaces during function. Clicking or popping in the joint is usually associated with displacement of the fibrocartilaginous disk (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 ear. 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. 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. Auscultation with a stethoscope is considered positive if 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 mouth opening:

The examiner stands in front of the patient and the patient is asked to slowly open the mouth widely without causing any pain. During opening if the mandible deviates to one side, it indicates a dis-equilibrium 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 right and then to the left side to the maximum without causing any pain. The movement should be similar on both sides. Reduced or abnormal movement on one side indicates TMJ problem. Pain during the movement also indicates TMJ problem.

Lateral movements of mandible

Lateral movements of mandible

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.  Any abnormality or pain during the movement is recorded.

Protrusive and retrusive movements of mandible

Protrusive and retrusive movements of mandible

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.

Examination of muscles involved in TMJ movement:

Temporomndibular joint is a complex joint. Various muscles involved in TMJ movement include masseter, temporalis, pterygoid (medial & lateral) and suprahyoid & infrahyoid muscles. Folllowing table describes various mandibular movements and muscles involved in the movement,

 Various mandibular movements and muscles involved in the movement

Actions
Muscles
Depression (Open mouth)Lateral pterygoid
Suprahyoid
Infrahyoid
Elevation (Close mouth) Temporalis
Masseter
Medial pterygoid
Protrusion (Protrude chin) Masseter (superficial fibres)
Lateral pterygoid
Medial pterygoid
Retrusion (Retrude chin)Temporalis
Masseter (deep fibres)
Side-to-side movements (grinding and chewing)Temporalis on same side
Pterygoid muscles of opposite side
Masseter

The examination of various muscles involved in mandibular movement can be done by activation of these muscles. For example masseter can be activated by clenching the teeth. Any pain associated with a specific mandibular movement should be noted.

Palpation of Masseter and Temporalis

Palpation of Masseter and Temporalis

Intr-aoral 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. Following is a brief description of three most commonly followed tooth notation systems,

Palmer notation System

In 1861 Adolph Zigmondy 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 Zigmondy system.

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 upper right third molar. The mandibular teeth are numbered through 17 to 32 beginning with lower left third molar. The universal system notation for primary dentition utilises upper case alphabets.

Universal notation system

Universal notation system

The Federation Dentaire Internationale Numbering System (FDI):

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.

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:

Total number of teeth present in oral cavity are mentioned here.

Notation

In the present case history discussion we are following the Federation Dentaire Internationale Numbering System (FDI). Although any system can be used but 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

Number of the 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 patient under examination.

Filled

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

Stains & 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.

Wasting Diseases

Wasting disease of the teeth is a broad term mainly used to describe the attrition, abrasion, and erosion of the teeth. In wasting disease of the teeth, the enamel is wear off, if the disease not controlled in its initial stage, it may involved the dentine and some time whole teeth get involved. The most systematic classification of tooth wasting diseases has been given by Grippo 4 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 masticator activity.
  • Abrasion: the pathological wear of tooth substance through bio-mechanical frictional processes, e.g. tooth brushing.
  • Erosion: the loss of tooth substance by acid dissolution of either an intrinsic or extrinsic origin, e.g. gastric acid or dietary acids.
  • Abfraction: the pathologic loss of …………………………..

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Key points to remember,

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Occlusion

Type of Angle’s malocclusion should be mentioned here.

Plunger Cusps/ Food impaction

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

Vertical impaction:

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

Horizontal (lateral) food impaction: It is seen in gingival inflammation in areas with enlarged gingival embrasure. Because of 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)5

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 & symptoms of food impaction include:

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

Periodontal findings may include

  1. Gingival inflammation – bleeding & foul taste.
  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. The interdental papilla fills the space upto tooth contact in normal conditions. However due to periodontal disease there is loss of interdental soft tissue and bone levels. Due to this, the position of interdental papilla recedes from its normal position. Nordland and Tarnow have given classification of interdental papillary hight.

Classification of papillary height:

According to Nordland and Tarnow (1998):

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Usually following classification given by Perry and Schmid (1996)6 is used to describe interdental embrasures,

Type I embrasure:

The gingival papilla fills up the embrasure space completely.

Type II embrasure:

The gingival papilla partially fills the embrasure space due to papillary recession.

 Type III embrasure:

The embrasure space is not filled. The gingival papilla has receded extensively or it is completely lost.

 

Interdental Aid Used for embrasure spaces

Interdental cleansing aid
Type of embrassure
Use
FlossType ICleaning in between teeth that have healthy, normal gingiva and type I embrasure
space
Waxed floss- indicated for tight contacts
Unwaxed floss- recommended for normal tooth contact
Tufted dental flossType I and Type IICleaning the abutment of teeth Under the pontic of a fixed partial denture
Under wires in orthodontic appliances

Floss holder with dental floss
Type IPeople with poor manual dexterity
Using only one hand
People with big hands
Toothpick or Toothpick holderType II & Type III Cleaning in between exposed roots
Interdental brushType II & Type IIICleaning in between exposed roots
Orthodontic and fixed appliance
Single-tufted brush (end-tuft, unituft)Type IIIOpen spaces between teeth
Difficult to reach areas
Fixed dental prostheses
A fixed partial denture
Pontic/abutment
Orthodontic appliance

Pathological tooth migration

Pathologic tooth migration is tooth displacement that results when the balance among factors that maintain physiologic tooth position is disturbed by periodontal disease 6.

It may present as extrusion, facial flaring, rotation, diastema, and drifting of affected teeth but most patients with pathologic tooth migration appear to have combined forms with the most common being facial flaring and diastema. The position of a tooth depends upon balance n the health of the periodontium as well as other factors such as occlusion, pressure of the lips, cheeks, tongue and oral habits.

Posterior bite collapse is one of the reasons for pathological tooth migration. Increased occlusal load on anterior teeth and reduced periodontal support in case of secondary trauma from occlusion together cause pathological migration of affected teeth.

In case of reduced periodontal support, forces from tongue lips and cheek put forces on teeth which are sufficient to cause pathological tooth migration.

Intra-oral soft tissue examination:

Examination of oral mucosa and other structures:

In intra-oral soft tissue examination, the first step is the examination of oral mucosa and associated structures. These include tongue, lips, buccal mucosa, floor of the mouth, frenum, soft palate, hard palate and the vestibule. Any abnormality associated with these structures should be noted and described in detail.

Examination of gingiva:

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

Structure of gingiva:

As demonstrated in the diagram, the gingiva has different parts like free gingival margin, free gingiva, free gingival groove, attached gingiva, mucogingival junction and alveolar mucosa.  Gingival margin is knife edge in healthy gingiva. In periodontal health and absence of periodontal pocket formation the gingival groove is 0.5 to 1.5 mm from the gingival margin approximately at level of bottom of gingival sulcus 7.

Diagrammatic representation of parts of gingiva

Parts of Gingiva

Normal gingava

Gingiva

Attached gingiva is non-movable gingiva as the name indicates. The functions of attached gingiva are:  it allows the gingival tissue to withstand mechanical forces such as mastication, speaking and toothbrushing. It also prevents free gingiva from being pulled away from the tooth when tension is applied to the alveolar mucosa. It is lined by keratinized stratified squamous epithelium. Width of attached gingiva is generally greatest in the………………………………………………

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It is also called epithelial attachment and the distance between the base of the attachment and the crest of the alveolar bone is approximately 1.0 to 1.5 mm. This distance is maintained in disease when the epithelium moves along the root surface and bone loss occurs. For detailed description please read “The dynamics of junctional epithelium”.

The interdental gingiva is the portion of the gingiva that fills the area between two adjacent teeth apical to (beneath) the contact area. The col is a valleylike depression in the portion of the interdental gingiva that lies directly apical to the contact area of two adjacent teeth.

Mucogingival junction is the junction of attached gingiva and alveolar mucosa. Alveolar mucosa is movable and is continuous with vestibule. It can be distinguished easily from the attached gingiva by its dark red color and smooth, shiny surface.

Identification of width of attached gingiva:

For identification of 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 gingival margin to mucogingival line. Subtracting the two measurements gives us the width of attached gingiva. Mucogingival junction is identified by stretching the lip/cheek laterally outwards. By doing so junction of 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 mucogingival junction when pushed coronally.

Histochemical method:

Histochemically iodine solution………………………………….

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Content available in the book

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Content available in the book

Probing technique:

One should know the exact probing technique to avoid any false readings during periodontal examination. 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.

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. 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.  Periodontal pocket may be present only on one surface of the tooth. Only the deepest recording is noted while probing one surface of the tooth.

Walking of the periodontal probe

Walking of the periodontal probe

.

Recording of pocket depth

Recording of pocket depth

Clinical probing depth:

The measurement of periodontal pocket depth during clinical probing is known as clinical probing depth. It has been shown in studies that in inflamed gingiva the periodontal probe penetrate the junctional epithelium even after application of recommended force of 0.20 to 0.25 N. So, the recorded measurement may be more than the actual probing depth.

Histological probing depth:

It is the exact periodontal pocket depth measured by making section of the gingiva and viewing it under the microscope.

Procedure of walking the probe:

The probe is kept…………………………………

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Probing the contact area:

It is done in two steps,

Firstly, the probe is kept parallel to the axis of the tooth with 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, 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 way of placing 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.

 By following the above procedures, probing depth measurements are recorded for 6 specific sites on each tooth:

  1. Distofacial
  2. Facial
  3. Mesiofacial
  4. Distolingual
  5. Lingual
  6. Mesiolingual

Colour of the gingiva:

The colour of “Clinically normal” or “clinically healthy” gingiva has a shade of pale or coral pink varied by complexion and pigmentation. In case of chronic periodontitis the inflamed gingiva may appear reddish pink/bluish in colour whereas in case of acute inflammation it may appear bright red in colour. It is important to note that when the products of the biofilm microorganisms cause breakdown of the intercellular substances of the sulcular epithelium, injurious agents can pass into the connective tissue, where an inflammatory response is initiated.  An inflammatory response means that there is increased blood flow, increased permeability of capillaries, and increased collection of defense cells and tissue fluid.  The changes produce the tissue alterations, such as in colour, size, shape, and consistency.

Colour of the gingiva depends upon:

  • Vascular supply.
  • Thickness of epithelium.
  • Degree of keratinization.
  • Physiologic pigmentation: melanin pigmentation occurs frequently in African Americans, Asians, Indians, and Caucasians of Mediterranean countries.

Contour of the gingiva: 

Healthy gingiva has a smooth arcuate or scalloped appearance around each tooth. It has knife-edged margins that adapts closely around the tooth. The papilla is pointed and pyramidal is shape filling the interproximal area between the teeth. If there is space between the teeth, the gingiva is flat or saddle shaped with normal colour. In case of inflammation the gingival margins become rounded due to oedematous and fibrotic changes, papillae become bulbous, flattened and blunted.

Consistency of the gingiva:

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

Surface texture:

Healthy gingiva has stippled appearance. It is usually known as the orange peel appearance. Stippling is a consequence of the microscopic elevations and depressions of the surface of the gingival tissue due to the connective tissue projections within the tissue 9. Clinically it can be seen by drying the gingival with the help of cotton and viewing it under broad day light. It is difficult to see it under focused light such as that of dental chair because lights 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.

Size:

Gingival enlargement is a common finding. 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 “gingival enlargement”.

Let us discuss how to record gingival enlargement. There are various indices which have been given to record gingival enlargement. Following are the most commonly used indices to record increased gingival size,

Ingles index for drug induced gingival enlargement (1999) 10 

 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 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.

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Position (recession):

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

Gingival exudate:

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

Bleeding on probing:

Bleeding on probing (BOP) is an indicator of tissue inflammatory response to bacterial pathogens. It is first sign of gingivitis. In the absence of normal signs of inflammation the gingival may not be free of inflammation. So, bleeding on probing is an important sign of gingivitis. In case of 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 the bleeding on probing may be reduced due to effects of nicotine. In case of acute inflammation the bleeding may occur after a slight provocation such as a short burst of compressed air.

Know more…….Significance of bleeding on probing:

Periodontal probing is carried out starting from diagnosis, throughout the supportive periodontal therapy to check the status of periodontium. Initially during diagnosis due to presence of inflammation and presence of calculus, accurate probing depth may not be done accurately. So, it is repeated after the removal of calculus when patient is maintaining a good oral hygiene and inflammation subsides. It provides accurate recordings which can be compared later on during the maintenance phase.

Bleeding on probing is one of the earliest sign of gingival inflammation 11. However, in some cases colour changes in gingiva have been seen without bleeding on probing 12. The amount of bleeding and ease of eliciting it depend upon the severity of inflammation. In case of mild inflammation bleeding may appear as a red line near the gingival margin whereas in case of severe inflammation bleeding on probing may be profuse. Bleeding on probing is not an indicator of attachment loss but simply indicates the presence of inflammation. While probing, the pressure exerted with the probe tip against the junctional epithelium should be between 10 and 20 grams. Clinically, this pressure is almost equivalent to the pressure required to blenching of nail bed. It must be remembered that the bleeding should be checked and confirmed upto 30-60 after the probing. During maintenance phase bleeding on probing is an important indicator of presence of inflammation.

 

McCall’s Festoons:

These are life preserver shaped rolled margins of gingiva. the gingiva in this case shows fibrotic properties.

Stillman’s Cleft:

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

Photograph showing McCall’s Festoon 

McCall's Festoon

Periodontal examination:

After the gingival examination is over, we record the periodontal findings. These include periodontal pockets & 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. Following image demonstrates the quadrant from where we start the periodontal examination, the chair side position  and how to go ahead systematically recording each and every surface to the tooth.

Systematic  Periodontal examination

Systematic  Periodontal examination

Before we go into details of periodontal findings lets first try to understand how periodontal pockets and clinical attachment loss is recorded. A graduated periodontal probe is inserted into the periodontal pocket till it stopped by resistance due to junctional epithelial attachment. The distance between gingival margin and the base of the pocket is known as pocket depth.

For calculating clinical loss of attachment we need to first find out the location of the cementoenamel junction because clinical attachment loss is the apical migration of junctional epithelium from its normal position at cementoenamel junction. If the cervical area of the tooth is covered by calculus it is difficult to find out the exact location of cementoenamel junction. So, in this case the calculus is 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 change in tactile sensation when the tip of the probe reaches the cementoenamel junction.  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 cementoenamel junction and the base of the pocket is clinical loss of attachment. Following images demonstrate the measurement of periodontal pocket and clinical attachment loss.

Measurement of periodontal pocket depth and clinical attachment loss

Clinical 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 physiologic 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. The increased mobility in the morning is attributed to slight extrusion of the tooth because of limited occlusal contact during sleep. During the waking hour, mobility is reduced by chewing and swallowing forces, which intrude the teeth in the sockets 13. Tooth mobility is graded clinically by applying firm pressure with either two metal instruments or one metal instrument and a gloved finger.

Classifications of tooth mobility   

Miller Classification 14:Class 0

Normal (physiologic) movement when force is applied.

Class I

Mobility greater than physiologic.

Class II

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

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 6:

Normal

Grade 1

Slightly more than normal

Grade 2

Moderately more than normal

Grade 3

Severe mobility Facio-lingually and /mesiodistally combined with vertical displacement.

 

Mechanical or electronic devices for the precise measurement of tooth mobility have been designed. The Muhlemann’s Periodontometer and Periotest are examples of such devices.

Furcation involvement:

The extension of inflammatory periodontal disease into the inter-radicular area of multirooted-teeth is known as furcation involvement.

Diagnosis of furcation involvement is based upon 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 as normally only two roots are present. 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 of the mesial surface. The distal furcation of maxillary molars is located more towards the midline, and may be detected from 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):

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. Class 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):

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):

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 upto 1 / 3rd of the inter-radicular height (1-3 mm).

Subgroup B: Vertical destruction of bone upto 2/3rd of the inter-radicular height (4-6 mm).

Subgroup C: Vertical destruction beyond the apical-third (7 mm or more).

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. It measures the vibratory pattern of the teeth when the teeth are placed in the contacting positions and movements. In this test dampened index finger is placed along the buccal and labial surfaces of the maxillary teeth and the patient is asked to tap the teeth together in the maximum intercuspal position and then grind systematically in the lateral, protrusive movements and positions. The teeth that are displaced by the patient in these positions are identified and graded. In the posterior teeth truma from occlusion can be detected with help of occlusion registration strips/articulating paper. High pressure points can be detected by the pattern of impressions made by registration strips/articulating paper.

The following classification system is used:

Class I fremitus : Mild vibration or movements detected.

Class II fremitus : Easily palpable vibration but no visible movements.

Class III fremitus : Movements visible with naked eye.

Mucogingival findings:

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

Recession:

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

Classifications of recession 

According to Miller: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:

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 abnormal frenal attachment. Here the lip is moved outwards, upwards for the upper and downwards for the lower 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 minimal width of attached gingiva for which mucogingival surgical procedures for increasing the width of attached gingiva are indicated. However, it has been show that if the patient has good oral hygiene maintenance, a minimal width of attached gingiva can be maintained without progressive recession.

Radiographic findings:

The radiographic analysis is required to know the extent of periodontal destruction in the form of bone loss. Intraoral peri-apical radiographs or orthopantogram are normally used to do radiographical analysis. In 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. Usually following chart is made to record radiographic findings,

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

Periodontal abscess:

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

Provisional diagnosis:

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

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 number of bacteria in plaque sample. This investigation is important for diagnosis of aggressive periodontitis cases and some special cases where repeated treatment is not able to control the disease progression.

DNA analysis for plaque micro-organisms:

The DNA analysis is for those bacteria which cannot be grown in culture. Here the plaque sample is subjected to various DNA amplification methods. Specific DNA for a bacterial species is allowed to pair with the DNA available in 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 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.

Any other specific test:

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

Biopsy:

In case of any growth excisional or incisional biopsy should be taken and sent for histopatological 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 patient.

Final diagnosis:

A complete and accurate diagnosis is required to make an appropriate treatment plan. The final diagnosis should include all the periodontal conditions as well as the systemic conditions which affect the periodontal disease progression for which the patient require treatment. We are here following the AAP world workshop 1999 classification system.

For example let’s take a patient who is diagnosed with generalized aggressive periodontitis. He is a diabetic. The occlusal analysis demonstrates secondary trauma from occlusion. So, the diagnosis should be “Generalized aggressive periodontitis with secondary trauma from occlusion with respect to (notation of teeth) complicated by diabetes”.

Prognosis:

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

Overall prognosis:

It is the prognosis based upon sum of various local, systemic, environmental and other factors which may affect the overall periodontal health of teeth. Factors which affect the influencing 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 upon local and prosthetic/restorative factors that have a direct effect on their prognosis. These factors include attachment loss, probing depth, furcation involvement; crown-to-root ratio, fixed abutment status and percent bone loss are the most important factors in determining tooth loss.

Detailed description of prognosis is available in “Determination of the prognosis”.

Treatment plan:

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.

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 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 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. Following is the list of procedures carried out in different phases of treatment plan,

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 treatment plan the patient is periodically evaluated for the periodontal status and needful treatment is provided according to disease condition. Details about supportive periodontal therapy are available in “The supportive periodontal therapy”. According to Merin’s classification the patient recall during the first year is different from the following years. Following is the patient recall schedule according to Merin,

Merin’s classification 6  

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)

Treatment notes:

It is the summary of complete treatment of the patient which includes the chief complaint and other components of history taking, clinical findings, various investigations, provisional and final diagnosis and treatment plan. The non-surgical and surgical therapy given to the patient is described with post operative healing and patient co-operation. Final outcome of the treatment given is explained and the schedule for follow-up examination i.e. supportive periodontal therapy is described.

Conclusion:

Case history recording is one of the most important steps required for an appropriate treatment of the patient. The above discussion was focused on the detailed description of case history. An in depth knowledge of the subject is required to record a complete and accurate case history. Every attempt has been made to gather as much as information as possible for above discussion. Readers are requested to put their comments, suggestions or any specific points which may further improve the topic by leaving a reply in the box below.

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Periobasics: A textbook of periodontics and implantology

2 Responses

  1. iyshasakeena says:

    hw can a take a printout of dis article for study purpose..
    its very informative and useful

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