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CHAPTER 30 CLINICAL DIAGNOSIS Proper diagnosis is the first most important step in treating the patient . Unless we have detected the presence of periodontal condition, identified its type, extent distribution ,severity and determined the underlying pathologic processes & its cause, it won’t be possible to undertake a successful treatment. Periodontal diagnosis is determined altered careful analysis of different findings. The different findings are not only collected or assembled but are relevantly correlated so as to arrive at a proper diagnosis. FIRST VISIT Overall appraisal of the patient. General evaluation, consideration of mental & emotional status, temparament, attitude & physiologic age.

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MEDICAL HISTORY : Health history –past, present. Relevant medical history. Systemic heart disease causing oral manifestations. Psychosomatic factors like stress and anxiety. Oral infections may lead to systemic conditions or affect them . Medically compromised- hemophilia, cardiac patients, handicapped. Occupational disease. Medicines taken. Bleeding tendency.

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Allergy. Puberty, pregnancy, menstruation, menopause. Family medical history. DENTAL HISTORY : Current illness Chief complaint : Bleeding, pain etc. PAST DENTAL HISTORY : Previous visits. Oral hygiene method History of orthodontic treatment History of previous periodontal problems & treatment taken for it Dental habits - bruxism, pan & tobacco chewing, smoking.

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INTRAORAL RADIOGRAPHIC SURVEY : 14 intra-oral films & posterior bite wing. Panoramic or orthopantomograms Casts Clinical photographs Review of initial examination – if no emergency care patient dismissed. we should study the radiographs and casts before the 2 nd visit.

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SECOND VISIT : Oral examination Oral hygiene- presence of food debris, mataria alba, plaque &stains Disclosing solution Mouth odors ,halitosis. Oral-extra oral Bacterial putrefaction of debris &plaque in gingivitis& periodontitis Proteins containing sulfur amino acids putrefaction volatile sulfur compounds Local sources – tongue, gingival sulcus, impacted food, ANUG, smoker breath, dehydration state, caries, artificial dentures, healing wounds.

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EXTRAORAL SOURCES : Lung conditions . Aromatic substance breath . Alcohol breath . Acetone odour of diabetes . Uraemic breath . EXAMINATION OF THE ORAL CAVITY . EXAMINATION OF THE LYMPH NODES . EXAMINATION OF TEETH : Examined for caries . Developmental defects . Anomalies of tooth form . Wasting . Proximal contact relationships .

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1. WASTING DISEASES OF TEETH : Defined: Any gradual loss of tooth substance characterized by the formation of smooth , polished surfaces, without possible mechanism of this loss . Different forms : Erosion . Abrasion . Attrition . a) EROSION : Wedged shaped depression in the cervical area with smooth, hard polished surfaces. Affects a group of teeth. May be confined to enamel or may extend up to dentine and cementum. Cause not known. Decalcification occurs by acid beverages, or citrus fruits along with combined effect of acid salivary secretion and friction.

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Sognnaes refers to these lesions as dentoalveolar ablations & attributes them to forceful friction between the oral soft tissues & the adjacent hard tissues. b) ABRASION : Refers to loss of tooth substance induced by mechanical wear . Results in saucer-shaped or wedge-shaped indentations with a smooth, shiny surface . Starts on exposed cementum surfaces and extends to involve the dentin . A sharp “ ditching “ appears at cementoenamel junction, due to softer cemental surface . CAUSES : Abrasive dentrifice . Use of horizontal brushing technique . Abrasion of incisal edges as a result of habits such as holding objects e.g. bobby pin or tacks between teeth.

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C) ATTRITION : It is occlusal wear resulting from functional contacts with opposing teeth . 2. DENTAL STAINS : Pigmented deposits on the teeth . 3. HYPERSENSITIVITY : a. Root surfaces exposed by gingival recession may be hypersensitive to thermal changes or tactile stimulation . b. Located by gentle exploration with a probe or cold air . PROXIMAL CONTACT RELATIONS : a. Slightly open contacts permit food impaction . Abnormal contact relationship initiate occlusal changes : Shift in median line between central incisors . Labial version of the maxillary canine . Buccal or lingual displacement of posterior teeth . Uneven relationship of the marginal ridges .

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TOOTH MOBILITY : All teeth have slight degree of physiologic mobility , which varies for different teeth and at different times of the day . Greatest on rising in the morning and progressively decreases . The increased mobility in the morning is due to slight extrusion of the tooth because of limited occlusal contact during sleep . During waking hours mobility is reduced by chewing and swallowing forces , which intrudes the teeth in the sockets . Single -rooted teeth have more mobility than multirooted teeth, with incisors having the most . Clinically checked by holding the tooth between two metallic instruments or with one metallic instrument and one finger .

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Grades of mobility are : Grade I : Slightly more than normal . Grade II : Moderately more than normal . Grade III : Severe mobility faciolingually & / or mesiodistally, combined with vertical displacement . Mobility beyond the physiologic range is termed abnormal or pathologic . CAUSES: Loss of tooth support ( bone loss ) . Trauma from occlusion . Extension of inflammation from the gingiva or from periapex into the periodontal ligament . Periodontal surgery . Tooth mobility is increased in pregnancy and is sometimes associated with the menstrual cycle or use of hormonal contraceptives . Pathologic process of the jaws that destroy the alveolar bone and / or the roots of the teeth .

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TRAUMA FROM OCCLUSION : a. Refers to tissue injury produced by occlusal forces . Diagnosis of trauma from occlusion is made from the condition of the periodontal tissues . Periodontal findings are : Excessive tooth mobility . Vertical or angular bone destruction . Infrabony pockets . Pathologic migration ,especially anterior teeth . PATHOLOGIC MIGRATION OF THE TEETH : Contributing factor is mouth breathing habit . Premature contact in posterior region contribute to destruction of the maxillary anterior teeth and to pathologic migration . Pathologic migration of anterior teeth in young persons may be a sign of localized aggressive ( juvenile ) periodontitis .

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SENSIVITY TO PERCUSSION : A feature of acute inflammation of periodontal ligaments . Percussion of a tooth at different angles to the long axis aids in localizing the site of inflammatory involvement . DENTITION WITH THE JAWS CLOSED : This can detect conditions such as : Irregularly aligned teeth . Extruded teeth . Improper proximal contacts . Areas of food impaction . All of these favor plaque accumulation . b. EXCESSIVE OVERBITE : Seen most often in anterior region . Cause impingement of the teeth on the gingiva and food impaction . Cause gingival inflammation, enlargement and pocket formation .

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OPEN BITE : Abnormal vertical spaces between maxillary and mandibular teeth . Occurs most often in anterior region . May lead to accumulation of debris, calculus formation, and extrusion of teeth . CROSS BITE : Maxillary teeth are lingual to mandibular teeth . May be bilateral or unilateral . Results in : Trauma from occlusion . Food impaction . Spreading of mandibular teeth, and associated gingival and periodontal disturbances . FUNCTIONAL OCCLUSAL RELATIONSHIPS : Important part of diagnostic procedures . Dentitions that appear normal when jaws are closed may present marked functional abnormalities .

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EXAMINATION OF PERIODONTIUM : Should be systematic, starting from molar region either maxilla or mandible . It is important to detect the earliest signs of gingival and periodontal disease . PLAQUE AND CALCULUS : Supragingival plaque and calculus can be directly observed and amount measured with a calibrated probe . Subgingival plaque detected with a sharp no.17 or no. 3A explorer . GINGIVA : Gingiva must be dried as moisture obscures detail . Gentle palpation is used to detect pathologic alterations in normal resilience and locating areas of pus formation . Following features should be considered : color, size, contour, consistency, surface texture, position, ease of bleeding, and pain .

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Gingival inflammation produce two basic types of tissue response : Edematous . Fibrotic . EDEMATOUS TISSUE REPONSE : A smooth, glossy, soft, red gingiva . FIBROTIC TISSUE RESPONSE : Gingiva is firm, stippled, and opaque, and margins appear rounded . PERIODONTAL POCKETS : SIGNS AND SYMPTOMS : A bluish- red marginal gingiva or bluish- red vertical zone extending from gingival margin to the attached gingiva . A rolled edge separating gingival margin from tooth surface . An enlarged, edematous gingiva . Presence of bleeding, suppuration, and loose, extruded teeth .

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Painless, localized or sometimes radiating pain or sensation of pressure after eating, which gradually diminishes. A foul taste in localized areas. Sensitivity to hot and cold. Toothache in the absence of caries. DETECTION OF POCKETS : Pockets detected and measured with a periodontal probe. Pockets not detected by radiographs. Gutta percha points or calibrated silver points used with radiograph to determine level of attachment of periodontal pockets. POCKET PROBING : Two different pocket depths are : Biologic or histologic depth. Clinical or probing depth.

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BIOLOGIC OR HISTOLOGIC DEPTH : Distance between gingival margin and coronal end of junctional epithelium. CLINICAL OR PROBING DEPTH : Distance to which probe penetrates. Probing force of 0.75N have been well tolerated and accurate. PROBING TECNIQUE : The probe should be inserted parallel to the vertical axis of the tooth and “walked” circumferentially around each surface of each tooth to detect the areas of deepest penetration. LEVEL OF ATTACHMENT VERSUS POCKET DEPTH : POCKET DEPTH : Is the distance between base of pocket and gingival margin. May change from time to time even in untreated periodontal disease.

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LEVEL OF ATTACHMENT : Distance between base of pocket and a fixed point on the crown e.g. CEJ. Changes in the level of attachment can be due to gain or loss of attachment. f) DETERMINING THE LEVEL OF ATTACHMENT : Gingival margin is located on the anatomic crown. Gingival margin coincides with the cementoenamel junction. Gingival margin is located apical to the cementoenamel junction. BLEEDING ON PROBING : Pocket elicit bleeding if gingiva is inflammed and pocket epithelium is atrophic or ulcerated. Noninflammed sites rarely bleed. It is earliest sign of inflammation. Bleeding vary from red line along gingival sulcus to profuse bleeding. After successful treatment , bleeding on probing ceases.

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DETERMINATION OF DISEASE ACTIVITY : The determination of pocket depth or attachment levels do not provide information whether lesion is in active or inactive state. Inactive lesions may show little or no bleeding on probing and minimal amount of gingival fluid and bacterial flora is mostly coccoid cells. Active lesions bleed on probing, have large amounts of fluid and exudate, and bacterial flora is spirochetes and motile bacteria. AMOUNT OF ATTACHED GINGIVA : Width of attached is determined by subtracting sulcus or pocket depth from total width of gingiva ( gingival margin to mucogingival line ). The amount of attached gingiva is considered insufficient when stretching of lip or cheek induces movement of the free gingival margin.

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DEGREE OF GINGIVAL RECESSION : During periodontal examination, the amount of gingival recession is measured with a periodontal probe from CEJ to the gingival crest. ALVEOLAR BONE : Alveolar bone levels are evaluated by clinical and radiographic examination. Probing determines : The height and contour of facial and lingual bones. The architecture of the interdental bone. PALPATION : Help to locate the origin of radiating pain that the patient cannot localize. Infection deep in the periodontal tissues and early stages of a periodontal abscess may also be detected by palpation.

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SUPPURATION : The presence of an abundant number of neutrophills in the gingival fluid transforms it into a purulant exudate. Clinically, the presence of pus in periodontal pocket is detected by digital pressure, visual examination is not enough. The purulent exudate is formed in the inner pocket wall, external appearance may give no indication of its presence. Pus formation does not occur in all periodontal pockets. LABORATORY AIDS TO CLINICAL DIAGNOSIS : When unusual gingival or periodontal problems cannot be explained through local factors, systemic factors are considered. Numerous laboratory tests aid in the diagnosis of systemic diseases.

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NUTRITIONAL STASTUS : Nutritional therapy in the treatment of periodontal disturbances, is determined by a nutritionist. Certain signs and symptoms have been identified with different nutritional defeciencies. Definitive diagnosis of nutritional deficiencies requires combined information revealed by the history, clinical and laboratory findings, and therapeutic trials. PATIENTS ON SPECIAL DIETS FOR MEDICAL REASONS : Patients on low- residue, nondetergent diets develop gingivitis, due to increased accumulation of plaque and food debris. Patients on salt free diets should not be given saline mouth washes, without physician’s consultation. Care should be taken to prescribe contraindicated food stuffs to patients suffering from diabetes, gall bladder disease, and hypertension.

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BLOOD TESTS : Analyses of blood smears, red and white blood cell counts, white blood cell differential counts, and erythrocyte sedimentation rates are used to evaluate the presence of blood dyscrasias and generalized infections. Determination of coagulation time, bleeding time, clot retraction time, prothrombin time, capillary fragility test, and bone marrow studies may be required at times. These tests are useful aids in the differential diagnosis of certain types of periodontal disease.