Data Collection—Diagnosis—Prognosis

10.1055/b-0034-56510

Data Collection—Diagnosis—Prognosis

Before any therapy is undertaken, clinical and other relevant data must be collected, to serve as the basis for diagnosis and a preliminary prognosis. The clinician must determine whether the case is to be comprehensive care or whether the patient simply seeks a solution to a local, specific problem. Even in the latter case, it is nevertheless always necessary to gather succinct systemic and special histories, in order to detect systemic disorders, medical risks, current medications etc.

Most important today is the comprehensive care patient, for whom a comprehensive treatment concept and definitive treatment plan must be painstakingly considered. This is only possible if the patient’s own wishes and notions are taken into consideration. In patients with severe periodontitis, exhibiting large bony defects, it may be necessary to obtain consultations from other specialists, e.g., oral surgeons, prosthodontists, orthodontists or even general medical practitioners.

The initial diagnosis and prognosis should always be viewed as a temporary or working diagnosis/prognosis. Of primary importance is the differentiation between chronic and aggressive forms of periodontal disease.

On the basis of the initial data collection, the preliminary treatment plan can be established, as well as alternative plans.

In this chapter on diagnosis, the following topics will be presented:

Findings

  • systemic and special patient history

  • “classical” findings

  • additional findings such as microbial tests and examination of the host response

Risk clarification

  • acquired and genetic factors

  • risk estimation

Charting

  • “classic” clinical data collection forms

  • digitized findings, electronic data collection

Diagnosis—preliminary/definitive

  • overall diagnosis, e.g., chronic periodontitis/Type II

  • diagnosis for individual teeth or surfaces of individual teeth (see Charting)

Prognosis—preliminary/definitive

  • for the patient as a whole

  • for individual segments of the periodontium

Data Collection—Examinations

Before performing extensive periodontal examinations, every patient should be subjected to a screening exam (e.g., PSR index, p. 73); this takes only a few minutes, and reveals whether periodontal lesions are present or whether other oral problems predominate.

If periodontal tissue destruction is detected, more extensive examinations are indicated. First among these are the “classic” examinations such as periodontal probing or measurement of attachment level (Fig. 383).

If there is evidence of special forms of disease, their etiologies and clinical course, additional facultative examinations should be performed. Such exams are especially indicated when one encounters:

  • copious hemorrhage with slight plaque accumulation

  • symptoms of disease activity (pus)

  • advanced attachment loss in young patients

  • elevated tooth mobility with mild bone loss

  • suspicion of a systemic disease.

Only after collection and evaluation of these exams will it be possible to establish a more precise differential diagnosis (e.g., aggressive periodontitis).

372 Checklist of Obligatory and Supplemental Clinical Findings Obligatory The obligatory, “classical” clinical findings must be recorded for every periodontitis patient before initiating therapy. This requires a special periodontal chart, which may be enhanced by additional forms for the history, hygiene index, gingival indices and functional analyses. Such data collection can be performed using traditional data collection forms or, today, using computer-enhanced and -printed data collection forms. In either case, most important is that the obligatory examinations be performed systematically, and that data be collected for each individual tooth. Supplemental In severe cases, e.g., in aggressive, progressive forms of periodontitis, and/or with the existence of severe functional disturbances and anticipated major reconstructions, supplemental examinations will be necessary. Such examinations, and their necessity, will be determined and selected for each individual patient. Beyond data collection, contemporary tests for specific bacteria and for host response in aggressive periodontitis cases provide an improved estimation of the risk potential and more targeted treatment planning (additional systemic medication?) and a more precise prognosis.

General Patient Health History

Each and every patient examination begins with the collection of the systemic, medical history. This is simplified by use of a health questionnaire, but such questionnaires do not replace a face-to-face discussion of the patient’s history. The health questionnaire must be rendered complete through targeted questioning. It is very important, today, to ascertain acquired and genetic risk factors.

The general medical history serves to protect patients with systemic diseases, and also protects the dentist and dental team from potentially dangerous infections (p. 211).

Special Patient Health History

In addition to questions concerning the general health of the patient, special areas of the patient’s background must be investigated: What was the patient’s motivation to seek out the dentist? What oral complaints does the patient have, and what does she/he expect from the dentist? Are caries, periodontal, or prosthetic problems of prime importance? Is the oral mucosa diseased? Is the patient experiencing pain? And last but not least: Does the patient complain of esthetic problems with teeth which are too dark, or large interdental spaces, tooth positional anomalies, “long teeth,” or excessively visible gingivae?

373 Medical History Form For new patients, the top section of the questionnaire contains the important personal data, which can subsequently be entered into the comprehensive, computerized office database. The medical history form should be completed by the patient in the waiting room, to save time. The medical history form comprises ca. 20 questions about the patient’s medical history, which can be answered yes or no. By signing the form, the patient acknowledges the validity of her/his answers. As mentioned previously, the dentist or dental hygienist should discuss the medical history form with the patient in order to enhance information. In the case of severe systemic diseases, the prudent dentist will consult the patient’s physician. All information provided by the patient must be held in strict confidence.

Classic Clinical Findings

Following collection of the systemic and special medical histories, the clinical examinations are performed. Recording of the “classic” findings (gold standard) remains of primary importance. It begins with a visual diagnosis. The entire oral cavity is inspected using a mirror. Even such a cursory inspection can reveal numerous manifestations of potential disease, e.g., plaque accumulation, gingivitis, gingival recession (Fig. 374). Brief inspection, however, can also lead to incorrect conclusions. For example, severe gingivitis may be incorrectly interpreted as periodontitis, or healthy appearing gingiva may mask true attachment loss. The important early diagnosis of periodontitis, including the existence of true periodontal pockets (clinical attachment loss, alveolar bone defects) can only be determined using the periodontal probe.

The clinical examination must be enhanced by radiographic diagnosis as well as vitality testing of all teeth. Elevated tooth mobility should be compared to the clinical findings (functional analysis, p. 174).

374 Cursory Inspection-Useless? A brief inspection of the oral cavity reveals what appear to be healthy gingival conditions. However, such inspection can reveal only superficial alterations of the oral mucosa and teeth (see right), but reveal nothing in the periodontal area. On the other hand, visual inspection can be life saving: a carcinoma screening, e.g., floor of the mouth, palate, lateral lingual borders should be routinely performed, especially in heavy smokers (stomatitis, leukoplakia). Teeth • Condition of the hard structures • Plaque accumulation • Restorations (oral hygiene) Gingiva • Erythema • Swelling • Ulceration • Recession Oral Mucosa • Effluorescences • Discolorations • Precancerous areas • Tumors
375 Pocket Probing In the same case (above), periodontal probing reveals that advanced periodontitis (labial attachment loss) is present in this area of healthy appearing gingiva. Right: The surgical site reveals: • Loss of 3 mm of bone • Burnished calculus in … • … a shallow buccal groove on the root surface
376 “Probing Depth 6 mm …” This statement provides no information concerning attachment loss or how much attachment remains on a tooth (blue columns): A 6 mm probing depth
− 3 mm pseudopocket
= 3 mm true attachment loss
B 6 mm probing depth
= 6 mm true attachment loss
C 3 mm gingival recession
+ 6 mm probing depth
= 9 mm true attachment loss

Pocket Probing—Probing Depth, Clinical Attachment Loss

The primary symptoms of periodontitis are loss of toothsupporting tissues (“attachment loss”) and the formation of true gingival and/or bony pockets. It is for this reason that any clinical examination of a periodontitis patient must include the measurement of pocket probing depths and attachment loss. Unfortunately, the significance of these clinical measurements is only relative, and not always congruent with the anatomic-histologic realities (Armitage et al. 1977, van der Velden and Vries 1980, van der Velden et al. 1986); the clinical measurements are much more dependent upon the state of health of the periodontium (tissue resistance).

The tip of the periodontal probe always penetrates into tissue that is below the sulcus or pocket fundus, even when the recommended probing force of 0.20–0.25 N is applied. With healthy gingiva and a normal junctional epithelium, the sulcus is histologically a maximum of 0.5 mm deep, but periodontal probing routinely yields a 2.5 mm measurement. The probe penetrates intraepithelially into the junctional epithelium. If gingivitis or periodontitis are present, the probe tip perforates the pocket epithelium and the infiltrated, vascular connective tissue (hemorrhage!) to the first intact collagen fibers that insert into cementum.

377 Probing Depth versus Pocket Depth This photomontage depicts a periodontal probe within a shallow, supracrestal pocket, with anatomically accurate spatial relationships. The pocket epithelium is perforated, and the gingiva is severely deflected laterally. It is only the healthy collagenous fiber bundles and/or alveolar crest of bone that stop the probe tip from further penetration. White Arrow pocket fundus Empty Arrow probing depth The measurement error between the true, histologic pocket depth and the clinical measurement (probing depth) can be up to 2 mm in severe periodontitis. For initial data collection, such error is usually of no consequence, but must be considered for the “before and after” comparisons following periodontal therapy. In most cases, the therapeutic result will be overstated, revealing an exaggerated reduction of probing depth. Courtesy of G. Armitage
378 Probing Depth A Healthy Gingiva The probe tip remains in the junctional epithelium (pink) and no hemorrhage is elicited. PD ca. 2.5 mm. B Gingivitis The probe tip perforates the junctional epithelium (bleeding) and stops only when it encounters collagen fibers. C Periodontitis The probe tip perforates the junctional epithelium (bleeding) and is stopped only by contact with bone. PD 7.5 mm
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Jul 2, 2020 | Posted by in Dental Hygiene | Comments Off on Data Collection—Diagnosis—Prognosis
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