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:
systemic and special patient history
additional findings such as microbial tests and examination of the host response
acquired and genetic factors
“classic” clinical data collection forms
digitized findings, electronic data collection
overall diagnosis, e.g., chronic periodontitis/Type II
diagnosis for individual teeth or surfaces of individual teeth (see Charting)
for the patient as a whole
for individual segments of the periodontium
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).
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?
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).
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.