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).
Figure 2-1 Causes of periodontal disease.
Data collection starts with a general assessment of the patient to investigate previous or current pathologic conditions that may be related to the onset or evolution of periodontal disease (neurologic disorders; digestive diseases; endocrine, blood, and coagulation disorders) and physiologic conditions (puberty and pregnancy). The general evaluation of the patient should also examine habits (smoking and alcohol consumption) and pharmacologic treatments. All information should be detailed in the patient’s folder and updated regularly.
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).
Figure 2-2 Thin and scalloped architecture.
Figure 2-3 Thick and flat architecture.
Figure 2-5 After causal therapy the morphology of the tissues has changed. The gingival tissue is firm and healthy pink, the recession of tooth 24 is still present, and the absence of plaque shows good oral hygiene.
Figure 2-7 Plaque index values can be reported on a graph where the ordinate is represented by the sum of the recorded values, and the abscissa corresponds to the time in months. The amount of plaque (plaque index score 240) decreases significantly after causal therapy (plaque index score 8 after 4 months).
Figure 2-11 Gingival index 3: spontaneous bleeding.
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:
Figure 2-12 A, Straight probe with 1-mm scaling marks, inserted between the tooth and the gum at a correct angle (i.e., parallel to the long axis of the tooth) and with a pressure of 30 g (slight pressure) to the bottom of the pocket. B, The curved probe is used for the furcation sites.
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 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.
BOP is the parameter used to assess the presence of inflammation. The probe is inserted to the bottom of the periodontal pocket, gently slid against the surface of the tooth or root. If this maneuver induces bleeding from the apical region of the pocket, the area is considered to be inflamed (Figure 2-14).
CAL is the distance between the cemento-enamel junction and the tip of the periodontal probe during probing. The presence of a crown requires the use of another fixed reference point (occlusal or gingival margin of the crown).
Tooth mobility is another important clinical parameter and is quantified by moving the tooth with the aid of two mirror or probe handles. Mobility is assessed in bucco-lingual, mesio-distal, and vertical directions. Periodontal disease causes increased tooth mobility because it reduces periodontal support. Values for tooth mobility range from degree 1 to degree 3.
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.
Figure 2-15 Intraoral radiograph.
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.