Chapter 10

Periodontal Diagnosis and Prognosis

Aim

This chapter aims to draw together the preceding text to enable practitioners to arrive at a practical working diagnosis upon which to develop appropriate treatment plans. (For further discussion of this see Quintessentials: Treatment Planning for the Periodontal Team.)

Outcome

Having read this chapter the reader should be able confidently to diagnose the majority of the more common periodontal diseases and to add detail to that diagnosis specific to the individual patient. The reader should also be able, on an individual patient basis, to identify local and systemic risk factors and to form an opinion about the degree of risk of future disease progression.

Diagnosis

Reaching a diagnosis and entering it in signed and dated patients’ records should be routine practice. This should occur after the examination is completed when the patient first attends for treatment and should then be repeated at all subsequent re-evaluation appointments during maintenance.

A diagnosis should be a concise description of the presenting disease in a particular mouth at a particular time. It is useful both on its own and in a comparative way over a period of time. Changes in severity and distribution of disease over time are often highlighted in this way giving an indication of rate of change as well as just the degree of change seen. Since the best indicator for future periodontal disease in a patient is their past disease experience, this information is very valuable.

Possible Periodontal Diagnoses

In the past, people tended to talk about periodontal disease as though it was just one disease entity. Over the years, however, there has been recognition that there are many different forms of periodontal disease, which just happen to affect the same tissues. These can be differentiated in a number of ways including the ages of the patients involved, the severity, type and distribution of destruction seen and the presence of systemic involvement. Classification of periodontal diseases is discussed in detail in Chapter 6, but when considering plaque-induced inflammatory periodontal diseases three main diagnostic situations arise:

1. A stable periodontium. This diagnosis is consistent with clinical health and is made if all the pockets are shallow enough to be cleaned by the patients themselves (usually taken to mean pocket depths of ≤ 3mm) and there is no bleeding from the base of the pockets upon gentle probing. This is the ideal situation since:

   • there is no evidence of the inflammation which we know often precedes and accompanies periodontal breakdown

   • the patient should be able to maintain low plaque scores – it is to be hoped below their own individual disease threshold.

   If a patient presents in this condition no treatment is required and it is reasonable to conclude that their susceptibility to periodontal disease is probably relatively low. Sometimes, however, patients with higher susceptibility who have undergone successful periodontal therapy may also present in this way during periodontal maintenance. It is known that periodontal treatment does not change the innate susceptibility to periodontal disease of any patient. However, with adequate therapy and good co-operation the disease may be controlled. In such cases presentation with a stable periodontium is a welcome finding, but there must be recognition that the disease is never cured and continued vigilance in the form of an appropriate individually designed maintenance programme is required.

2. Gingivitis. This term means that there is no loss of attachment present (hence any pockets present must be false pockets), but there is redness, swelling and bleeding on probing from the base of the pockets, following gentle probing. As discussed in Chapter 5, it is known that gingivitis is the first stage of periodontal disease and that some patients never progress beyond this. Unfortunately, other patients with higher susceptibility to periodontal disease progress rapidly through gingivitis and quickly develop periodontitis. There are two main descriptors which should be applied to gingivitis to provide a clearer diagnostic picture. These are:

   • Whether the condition is acute or chronic. There is a great deal of confusion about these terms. It has often been assumed that “acute” means that the condition being described is severe in nature while “chronic” implies lower severity. The terms correctly, however, describe the length of time for which the condition has been present, with acute meaning for a short time and chronic describing a greater duration (see Chapter 6). There is no doubt that the terminology can be confusing, but in periodontal terms acute forms of gingivitis may include conditions such as NUG, primary herpetic gingivostomatitis or lateral periodontal abscesses. However, as previously discussed, such conditions may, more rarely, also follow a chronic course and the majority of gingivitis cases fall into one of the chronic gingivitis categories.

   • Whether the condition is localised or generalised. There are no hard and fast rules about the differentiation between the two but the 1999 World Workshop on Periodontal Disease Classification suggests that the term “localised” be used if up to 30% of the mouth is affected and “generalised” if more than this figure is involved. A description of the affected teeth and surfaces involved in the localised form of the condition may be included. This addition is not necessary when the condition is generalised.

   An example of a diagnosis would thus be “localised chronic />

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