Formulating a Periodontal Diagnosis

An accurate periodontal diagnosis involves the merging of our current understanding of disease with patient‐specific information.

Historically, the American Academy of Periodontology together with the European Federation of Periodontology have worked to provide updated guidelines for diagnosis based on current scientific understanding. In 2017, a series of papers were published as the Classification of Periodontal and Peri‐Implant Diseases and Conditions. The workshop aimed to clarify previously unclear nomenclature and provided a completely restructured method of periodontal diagnoses.

In this format, a branch of peri‐implant diseases and conditions was created to address implant‐related issues and standardize specific diagnoses. This reflects the growing importance of implant therapy in the field of periodontics.

Data collection in the form of a systematic approach to patient examination is essential in the process of determining an accurate diagnosis. Complete records should be gathered including relevant systemic and local factors, history of condition, and thorough examination of the patient. There are factors to consider in the process of data collection can be informed by our current understanding of periodontal disease activity. For example, certain infections periodontal conditions have been attributed to the presence bacterial biofilm and the host response process. Thus, the presence or absence of certain bacteria can be used to inform a diagnosis.

Periodontal Health and Gingival Health

Defining and recognizing periodontal health are important in order to recognize standards in which disease can be compared. Periodontal health can be defined as the state in which tissues are free from periodontal inflammation.

There is a difference between histological and clinical periodontal health: Histologic features of health include a low bacterial load with bacterial species mostly gram‐positive and nonmotile such as Streptococcus and Actinomyces species. The confirmation of this status may not be practical for all patients in a clinical setting. Instead, clinical indicators of health include information, which can be gathered chairside during a thorough examination including bleeding upon probing (BOP), probing depth, radiographic bone levels, and tooth mobility.

Host determinants in clinical health include microbiological, host, and environmental categories. Each of these may be considered a predisposing factor, which contributes to the accumulation of dental plaque or a modifying factor or one which alters the way in which an individual responds to subgingival plaque accumulation. Some of these factors may be controllable while others are not.

1. – Local predisposing factors: periodontal pockets, dental restorations, root anatomy, tooth position, and crowding
2. – Systemic modifying factors: host immune function, systemic health, and genetics

While the determinants of health are important in understanding the disease process, the indicators of clinical health are essential for the practitioner to recognize and accurately diagnose a periodontally healthy patient. The best method for monitoring the health or inflammation of gingival tissues is through bleeding on probing (Lang et al. 1986), usually measured as bleeding provoked by applying a probe to the bottom of a gingival sulcus or pocket.

Other factors such as periodontal probing depth, radiographic bone loss, and tooth mobility have been used in the past; however, these are not always useful in assessing patients who have experienced periodontal disease in the past.

Diagnoses of periodontal health can include clinical health on an intact periodontium or clinical health on a reduced periodontium. Patients with a history of disease can further be identified as stable periodontitis patients or non‐periodontitis patients.

Gingivitis: Dental Plaque‐Induced

Gingivitis is defined as inflammation of the gingival tissues. The most common form of which involves a plaque‐induced host response. Studies on the natural history of gingivitis in man have found that there are a greater number of bacteria in gingivitis sites compared with healthy sites. Additionally, there is a shift from Gram positive, non‐motile species to a more Gram negative, motile species.

Gingival inflammation can be categorized according to its extent and severity. Gingivitis is considered localized when <30% of teeth are affected and generalized when >30% of teeth are affected. Additionally, mild gingivitis occurs in an area with minor change in color and little change of texture; moderate in areas with glazing, redness, edema, enlargement, and BOP; severe in areas of overt redness and edema with bleeding occurring with slight touch.