Introduction

Periodontal diseases manifest themselves in the majority of the adult population. Therefore, it is mandatory that all patients presenting to a general practitioner, regardless of the first impressions made of their periodontal health, are screened to identify those at risk of periodontal disease who will need a more comprehensive assessment prior to making an appropriate diagnosis. A failure to assess the periodontal health of a patient in any routine dental examination is potentially a negligent omission.

An assessment of the clinical signs and symptoms along with the medical history generally form the basis for establishing the diagnosis and assessing the severity of periodontal disease. From the first visit, the clinician should make an overall appraisal of the patient, including taking a full history. This will subsequently need updating at every visit, and certain historical information is crucial for both the diagnosis and to form the background for developing the most appropriate treatment plan for the individual patient.

What factors in the dental history might indicate periodontal disease is present?

Often, patients are unaware that they have periodontal problems, which may cause significant symptoms only at a relatively late stage when teeth become loose or painful. It is common for patients to complain that their gums bleed, particularly on brushing or flossing; however, many patients accept this as being a normal occurrence and not an indicator that more significant disease is present. As disease progresses, particular concerns may be conveyed that teeth are becoming loose, gaps are opening up, and the teeth are becoming uneven or the gum is receding. This may make the patient particularly anxious about losing teeth or about their appearance.

The patient may also have pain, which can present in a variety of ways, from a dull pain after eating or on chewing to a more acute pain of short duration particularly after cold food or drinks.

A dental history should aim to address the following areas:

What is the relevance of a patient’s medical history to his or her periodontal care?

Many aspects of a patient’s medical history may be particularly relevant to his or her periodontal care. These are discussed further in subsequent chapters but may include the following:

Why is it necessary to take a social history?

A social history should include details of habits such as tobacco use, including smokeless tobacco (see < ?xml:namespace prefix = "mbp" />Table 1.1 for effects on periodontal health), and alcohol consumption. A smoking history should include not only whether patients are current smokers but also if they have smoked in the past, when they quit smoking, how many they smoked or are smoking now, and whether are they interested in quitting.

Table 1.1 Effects of smoking on periodontal health

A social history may also give information about the patient’s occupation that is both useful for interacting with the patient and may indicate specific dental issues (e.g., wind instrument player and importance of aesthetics in a job). It can also provide information about the patient’s ability to attend appointments regularly and identify issues such as stress in a patient’s life.

Clinical periodontal examination

The examination should start with a general extra- and intraoral examination of the soft tissues, temporomandibular joint (TMJ), and lymph nodes to look at the mouth and surrounding tissues as a whole.

The periodontal tissue examination should be systematic, starting with an appraisal of gingival colour and contour, oral hygiene, and aesthetics. Oral hygiene and gingival inflammation can be measured in a number of ways using both full mouth scoring systems and partial scoring systems (Table 1.2), which act as a relatively objective way of scoring plaques present over time and reflect a patient’s compliance with the oral hygiene instruction given. Objective measurements of plaque and bleeding are required to be able to measure and record changes in oral hygiene over time and are useful motivational tools as positive feedback for patients. The full mouth plaque and bleeding score is commonly used because it records the mesial, distal, buccal, and palatal/lingual surfaces of all the teeth present (Figure 1.1) in a dichotomous score (plaque present/absent). The graphical representation can act as a useful aid to the patient to illustrate and map out areas on which he or she needs to focus. Partial scoring systems often use Ramfjord teeth (Figure 1.2), which are considered to be a valid representation of full mouth scoring, particularly for epidemiological purposes. The main advantage of partial scoring indices is that they can be performed very rapidly; however, they fail to provide relevant site-specific information about plaque and bleeding distribution. Plaque scoring is much more accurate if it is carried out after disclosing the patient.

Table 1.2 Examples of partial and full mouth plaque scoring indices

Fig 1.1 Plaque and bleeding scores.

Fig 1.2 Ramfjord teeth are used as a representation of the full mouth for evaluation of plaque (FDI notation: 16, 21, 24, 36, 41, 44).

What do I need to carry out a BPE and how often should it be recorded?

A special probe called the WHO probe is required, and the key features are described in Figure 1.3. The BPE should be carried out on all new patients:

• For patients with codes 0, 1, or 2, the BPE should be recorded at least annually.

• For patients with BPE codes of 3 or 4, more detailed periodontal charting is required.

Fig 1.3 The WHO-C (clinical) probe. The key elements of this probe are a ball end with a 0.5-mm diameter, a black band at 3.5–5.5 mm, and a second black band at 8.5–11.5 mm.

BPE cannot be used to assess the response to periodontal therapy because it does not provide information about how sites within a sextant change after treatment. To assess the response to treatment, probing depths should be recorded at six sites per tooth pre- and post-treatment.