2: Causal Therapy

Causal Therapy

Causal therapy is the first stage in the treatment of periodontal disease, a complex multifactorial condition whose manifestations are caused by pathogenic bacteria in association with other local and systemic factors (oral hygiene, environment, host susceptibility). Therefore the treatment of periodontal diseases needs a multilevel therapeutic approach (Figure 2-1).

Diagnosis

Proper causal therapy requires a scrupulous and accurate diagnosis. The diagnostic process entails collecting and interpreting clinical and radiographic information.

Clinical Records

Clinical documentation consists of collecting data through the following:

Examination

The tissues are examined to assess the shape, color, surface appearance, size, and architecture of soft tissues. The periodontal tissues can be classified into two main types: thin scalloped architecture and thick flat architecture (Figures 2-2 and 2-3).

The examination also assesses the presence of plaque deposits on the dental surfaces using the plaque index (Silness and Löe, 1964), whose values range from 0 to 3.

The collected data should carefully be recorded on a special chart to be consulted and updated at every periodontal maintenance appointment in order to observe changes over time (Figures 2-4 to 2-7).

During examination, the extent of tissue inflammation is determined by means of the gingival index (Löe, 1967), whose values range from 0 to 3 (Figures 2-8 to 2-11).

Periodontal Probing

Probing makes it possible to evaluate the loss of attachment (clinical attachment level [CAL]), which is a pathognomonic sign of periodontitis. Probing is performed with straight and curved probes that have 1-mm scale markings (Figure 2-12). Using a probe, the specialist can determine the probing access to the sulcus and bifurcations, respectively, and can assess the presence of calculus on the root surface, the topography of the periodontal pockets, BOP, and any retraction of the tissues after treatment. Probing is affected by several factors:

At this stage the main difficulty is the exact reproducibility of periodontal probing. For this reason several methods for automatic probing have been proposed, but the results of the various studies comparing automatic and manual probing do not show any significant difference or advantage. To minimize the variability in results, all the periodontal probing of a patient should ideally be performed by the same operator.

Probing permits assessment of the following clinical parameters, which is crucial for diagnosing periodontal disease.

Probing Depth

Probing depth (PD) corresponds to the depth of the periodontal pocket and is represented by the distance between the gingival margin and the bottom of the pocket, which is the ideal habitat for periodontal pathogenic bacteria (Figure 2-13; see also Figure 2-12).

It is important to underscore that pocket depth is not an absolute parameter: It is influenced by several factors and should be evaluated with other parameters. In particular, in the case of recession the PD value will be very low because its measurement refers to the gingival margin, which has undergone apical migration. In the presence of hypertrophic gingivitis the absolute value of the PD will instead be high because the gingival margin has moved toward the crown as a result of tissue edema.

Radiographic Records

Indications and Characteristics

Among the dental radiographic examinations, the orthopantomogram is not considered useful for diagnosis of periodontal disease, whose detection requires intraoral radiographs taken with a holder and parallel-beam technique (long cone technique) producing minimal image distortion.

Radiographs are stored and organized on special supports (full mouth series) (Figures 2-15 and 2-16).

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Figure 2-15 Intraoral radiograph.

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Figure 2-16 Full mouth series.

Intraoral radiographs make it possible to identify dental features such as the size, shape, and position of the roots; size of the radicular trunk; size of the pulp chamber; erosions; caries; fillings or other types of restorations; apical and periapical alterations; and the presence of calculus on the root surfaces.

They can also show bone characteristics such as the presence or absence of the lamina dura, the status of the interproximal ridges, and any vertical and/or horizontal resorption.

In any case, the radiographic examination must be supplemented with clinical records because of the following intrinsic limitations:

• Radiographs do not show the true buccal and lingual conditions, as the presence of mineralized tissues can disguise them.

• It provides a two-dimensional image of three-dimensional structures. For an in-depth examination of the anatomic conditions, one should use computerized axial tomography (CAT) scans.

• The radiographic image is subject to deformations caused by x-ray beam inclination and the shape and thickness of the examined structures.

• During the initial phase of the disease, when the clinical symptoms may already be apparent, the radiographic image does not show signs of pathologic alterations.

• Errors of execution or centering, poor film quality, and the wrong exposure time or development can affect the interpretation of radiographic images.

• Radiographs show changes in the mineralized portion of the periodontium but not in the soft tissues.

• The radiographic image of the destruction of the mineralized periodontal components is always less severe compared with the real status.

Jan 1, 2015 | Posted by in Dental Materials | Comments Off on 2: Causal Therapy
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