The most important aspect of periodontal treatment is a thorough patient evaluation as without it, neither comprehensive diagnosis nor treatment planning is possible. Patient evaluation must investigate the systemic background of the patient’s periodontal condition and look for local factors that influence the disease. The systemic background can be investigated through an attentive review of the medical history and past treatment. Detail-oriented extraoral and intraoral examinations can reveal various local factors that contribute to a patients’ periodontal disease. In some cases, additional endodontic, radiographic, microbiologic, histologic, and genetic tests may need to be used to investigate unusual disease.
Learning Objectives
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Assess the systemic context of a patient’s periodontal condition.
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Evaluate a patient’s clinical periodontal condition for current status and local contributing factors.
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Use radiographic imaging and adjunctive tests to corroborate periodontal findings and uncover contributing factors.
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Prepare a problem list that leads to an etiology-based treatment plan.
Case
A 56-year old Caucasian female presented with pain from several teeth and wants to “take better care of her teeth.” She states that the pain is mild and tolerable but fluctuates in intensity and never goes away completely. The pain comes from several teeth in the mouth, which makes it hard for her to point out the worst offending tooth. She noticed that it usually is triggered by eating cold or sweet foods, such as chilled soda, and it diminishes after a while when she does not eat. She did not seek care for the toothache elsewhere and tried avoiding seeing a dentist because of concerns about treatment costs. She denies having any anxiety about treatment. She has not seen a dentist since 5 years ago, where she received sporadic dental care. She uses a soft manual brush for about a minute twice a day to brush her teeth with a scrubbing technique, uses floss once a day, and uses a generic antiplaque mouth rinse once daily.
She does see a physician regularly, who prescribed 100-mg Losartan, 50-mg Levothyroxine, and 100-mg Gabapentin for her to take once daily, and takes these medications to treat her hypertension, hypothyroidism, and nerve pain in her hip. She denies having any other conditions; taking any supplements, recreational drugs, or using tobacco.
Extraoral exam reveals no findings other than a mild popping sound in the left temporomandibular joint (TMJ) halfway during mouth opening and closing. Intraorally, tissues appear normal other than marginal gingival erythema, and a small amount of purulent discharge next to no. 19 in an area of deeply erythematous marginal gingiva. Wear facets are present on most teeth and there are abfractions on the canine and first premolar facial surfaces, which also were the sites of facial gingival recession. A heavy centric occlusal contact was noted between no. 19 and no. 14, with no. 14 slightly supraerupted and no. 19 slightly submerged compared to teeth nos. 18 and 15. The patient is in Angle Class I with a deep overbite and shallow overjet.
The periodontal exam reveals several areas with slightly increased pocketing to about 5 mm around some molars, and a deep, wide 9-mm pocket on the facial side of no. 19. At this site, probing caused some discomfort to the patient, and when the probe was withdrawn, several drops of purulent discharge began to seep from the pocket entrance. This site was also coincident with the marginal erythema noted earlier, and the roof of the furcation could be felt about halfway under the tooth.
Radiographic examination showed mild generalized radiographic bone loss that correlated with the clinically observed mild generalized clinical attachment loss. There was a well-defined periapical radiolucency at tooth no. 14, and recurrent caries on the mesial surface of no. 15. There also was an area of reduced density within the furcation area of no. 19, and somewhat irregularly shaped crestal bone in all molar areas. Several crowns displayed open margins, especially on teeth nos. 3, 14, and 31. Tooth no. 29 had significant recurrent caries on the distal side of the tooth. Several of the patient’s direct restorations had a degraded radiographic appearance with either poorly defined interproximal contacts, rough surfaces, restorative material overhangs, or a thick bonding agent-composite fill interface.
The patient was asked again to identify the area with the most severe pain, and the patient pointed to the upper left side. Closer inspection of these teeth revealed that the crown on no. 14 was slightly loose. The patient reported that the crown and associated root canal was completed more than 10 years ago. The patient did not remember any problems experienced during and after treatment back then. Pulp testing was performed on teeth nos. 13, 14, and 15, with an ice pellet. Tooth no. 13 produced a normal short-lived episode of pain when cold was applied and tooth no. 15 a slightly more pronounced, but still short-lived episode of pain. Unexpectedly, tooth no. 14 produced pronounced and lingering pain when cold was applied to the tooth, and it replicated the patient’s pain complaint most closely. None of the three teeth produced pain on palpation or percussion.
Clinical appearance (Fig. 2.1) and radiographs (Fig. 2.2) are as shown in these figures.
Findings in the periodontal chart are as follows:
What can be learned from this case?
Unlike the patient case presented in Chapter 1, this patient presents with definite signs of periodontal disease, such as pocketing, bleeding and suppuration on probing, gingival recession, furcation involvement, and bone loss. Moreover, this patient presents with tooth pain.
Pain should always be addressed first. One way to diagnose oral pain is to consider the possible sources and rule them out based on clinical findings.
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Nonodontogenic pain is unlikely. There is no history of neurologic conditions (referred pain, headaches, migraines, and neuralgias) or signs and symptoms of aggressive tumors (swelling and unexpected weight loss). The examination did not reveal signs of significant TMJ conditions, such as a displaced disk or arthritis (no pain on palpation and normal exam/radiographic findings).
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Pain from occlusion is unlikely as there is no pain during percussion or occlusion
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In tooth no. 19 suppuration and deep pocket indicate periodontal infection and severe inflammation, which cause discomfort during probing.
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Teeth nos. 3 and 31 have open margins, and tooth no. 15 has recurrent caries. These teeth may produce sharp, short-lived pain when air is blown over the exposed margins or caries but have otherwise normal pulp vitality test results. Since the patient experiences pain after eating sweets, recurrent caries at no. 15 is a more likely source of pain.
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Tooth no. 14 is likely the main source of the patient’s pain as testing replicated symptoms. Although periapical radiolucency suggests previous root canal treatment, intense pain during pulp vitality testing suggests irreversibly damaged pulp tissue. Given the radiographic presentation, it seems likely that root canal treatment failed or canals were missed during root canal treatment.
Acute infections have the second highest priority in treatment, and purulence at no. 19 suggests active infection. Here, a severe periodontal disease resulted in an isolated area of large bone loss that can be visualized when changing contrast and brightness on the digital radiograph, or with adjusting voltage and exposure time for several repeated conventional radiographs of no. 19 (Fig. 2.3).
Fig. 2.3 Changing density and contrast on digital radiographs can be used to identify the shape and number of walls around bone defects. The process is as follows: (a) Adjust contrast so that it shows the maximum of bone structure, and lower brightness so that only the most radiodense objects such as dentin, enamel, external oblique ridge, and restorations remain. (b) Increase brightness until the densest parts of crestal bone appear. This will also outline the apical base on any bone defects. (c) Increase brightness further until faint parts of the alveolar crests appear, showing any walls of bony defects such as the bone spur distal to tooth no. 18 and the shallow vertical defect between this bone spur and the external oblique ridge. Notice also the faint line outlining the likely facial bone loss around the furcation of no. 19. (d, e) Increase brightness even more to show the faint gingival shadow (as shown in e with the arrows), which provided an estimate of tissue thickness. (f) Gingival shadow and bone defects outlined. Note the U-shaped area of bone loss at the furcation of tooth no. 19, the shallow 1-wall defect mesial of no. 19, and the shallow, but complex multi-wall defect at the distal of tooth no. 18 created in part by the overlying external oblique ridge. Thickened soft tissue overlies this multi-wall defect as seen by the thick tissue shadow (white line, arrows).
Isolated areas of bone loss should trigger a search for local factors enhancing periodontal disease. In this case, the local factor is the furcation involvement and the unique occlusal relationship between no. 14 and no. 19 in this case. Tooth no. 14 protrudes slightly in relation no. 15, and no. 19 is slightly submerged in relation to no. 18. Both teeth have wear facets and there is a heavy occlusal contract at maximum intercuspation and in excursive movement. Chronic excessive occlusal force from this heavy contact may have led to increased attachment loss and bone loss in response to the already occurring periodontal infection near the furcation entrance. For no. 14, the heavy occlusal force may have contributed to the cemental breakdown under the crown, which lead to the crown loosening and bacterial reinfection of the root canals.
The 5-mm pockets seen around the molars with isolated bleeding on probing are also linked to local factors: subgingival, open margin at the interproximal space between teeth nos. 2 and 3; open margin, open contact, and rough surface at the interproximal space between nos. 14 and 15; recurrent caries at no. 29; and bulky contour of no. 30.
The patient’s general level of periodontal disease activity is mild and typical for her age and dental history, since plaque levels are low and there are no major systemic contributing factors at this time.
The abfractions and facial gingival recession seen in this case are most likely related to occlusal trauma and are linked to the wear facets of those teeth. While not indicated in the patient’s dental history, the presence of wear facets and abfractions suggests that the patient bruxes her teeth and this possibility must be considered during the treatment.
Finally, the low amount of keratinized gingiva abbreviated as “MGJ” in the chart since it marks the position of the mucogingival junction (MGJ) relative to the gingival margin and lack of it at the canines are associated with a shallow lingual vestibule and numerous frenum attachments on the facial side of the mandibular ridge. This lack of MGJ may make brushing mandibular teeth more difficult, and may have contributed to periodontal disease activity at some point in the past. Currently, however, plaque levels are low, and the lack of MGJ may not be a significant factor in this patient.
Assessing the Systemic Context of a Patient’s Periodontal Condition
Chief Complaint and the History of Present Illness
One of the most important aspects of a patient interview (see ?Video 2.1) in preparation for a comprehensive periodontal exam is to let the patient voice their concerns and treatment goals. Allowing the patient explaining their symptoms and probing the patient’s concerns with the right type of skilled open-ended questioning often provide important clues for fast diagnosis. For efficiency, patient assessment should start with an open-ended question like “What brings you here today?” The answer, the “chief complaint” (CC), should be recorded verbatim, and usually presents the patient’s most pressing concern. This should be followed up with open-ended, but directed questions to find out details about the patient’s CC, which are collectively known as “history of present illness.” Whereas most patients seeking care at a general practice will present with concerns unrelated to periodontal disease, a small proportion of patients will present either because they feel they need a “cleaning” or actually have symptoms of periodontal disease.
CCs related to periodontal conditions usually fall in the following categories, and should be investigated with the following questions:
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“Want cleaning”/ “want check-up for gums:” What makes you feel you need a cleaning/exam? Any concerns about the gums? When were the last cleaning/exam?
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Referrals/ “was sent here:” Who referred patient? Why? What treatment was done prior to the current visit?
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“Loose teeth”/tooth mobility/shifting of teeth: What teeth are loose/have shifted? How bad? How does it affect eating, drinking, speaking, and swallowing? When noticed? Any gum problems before?
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Pain: How severe? (use a visual analog scale) Where? How does it feel like? When does it happen? When first noticed? Is it changing in any way since it first started? What makes it worse triggers it? What makes it better? How do you manage your pain? How does it affect you? Have you already seen someone else about the pain?
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Gingival bleeding/swelling: Where? What triggers it? How severe? When did the patient notice it for the first time? What makes it better? Had previous treatment for it?
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Gingival recession: Where? When first noticed? Noticed any changes recently? Had previous treatment for it?
The patient’s responses are often relevant for diagnosis as the symptoms usually correspond to clinical findings or certain periodontal diseases. If the CC is about:
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Wanting a “cleaning” or “check-up,” then there will likely be significant calculus and plaque accretions. This may also indicate difficulty to commit to regular periodontal care.
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Being “sent here” or “referred here,” usually this implies deep pockets, severe attachment loss/bone loss, mobile teeth, or extensive subgingival calculus deposits.
If the CC mirrors any of the following symptoms of periodontal disease, such as:
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“Loose teeth,” it is most likely related to tooth mobility caused by severe attachment and bone loss. These patients may also report that teeth have “drifted” or “shifted” recently, and these patients may have some difficulty with eating or speaking as teeth no longer occlude properly, or the tooth mobility causes pain. In our experience, a CC of “loose teeth” most likely is associated with generalized severe periodontitis, or with combined periodontal endodontic lesions (more of this in Chapter 3). Much less common, but important to remember is that tooth mobility can also be caused by occlusal trauma, abnormal root anatomy (short tooth roots, root resorption, orthodontics-associated root resorption, and microdontia), rare genetic syndromes, and rare malignancies such as Langerhans’ cell histiocytosis.
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“Bleeding gums,” it usually indicates severe gingival inflammation. Gingival bleeding may be noticed by patients after brushing, flossing, or eating solid foods. Rare, but important to remember is that spontaneous gingival bleeding can also occur in patients with necrotizing periodontal diseases, severe coagulation defects, platelet disorders, and acute myeloid leukemia.
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Pain, it usually indicates severe disease if the pain originates from the periodontal tissues. While periodontal disease in most of the patients causes little to no pain, severe inflammation in the periodontal tissues can produce a constant, “dull,” “sore,” and maybe “itching” type of pain. Often, patients with gingival pain report that scratching or brushing the gingiva vigorously relieves pain. Chewing may aggravate the pain. Sharp pain is either related to occlusion (pain occurs or gets worse during chewing) or a pulpal condition (replicable with cold or other types of stimulation).
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“Receding gums” or “long teeth,” it is related to gingival recession either caused by severe periodontal disease or other factors that cause isolated areas facial or lingual recession. Patients may also complain about the appearance of brown or yellow root surfaces, exposure of metal crown margins, spaces appearing between the teeth, or the “gums receding.” If there is a generalized loss of gingiva, with the loss of interproximal tissues, then the patient most likely has a form of periodontitis. If the recession is limited to a few teeth, local factors as explored with the questions above are more likely the cause of recession.
Medical History
A thorough medical history and review of systems are essential for safe patient care and are useful for the identification of risk factors linked to periodontal disease or treatment complications. For these reasons, it is important to obtain the following information.
Physician Contact Information
For patients with complex medical histories, it is often necessary to collaborate with a patient’s primary physician and medical specialists. Therefore, the names, phone numbers, and fax numbers of a patient’s primary physician and medical specialists should be recorded and verified either prior to the exam or before the patient leaves after the initial visit.
Medications
The most important aspect of the medical history is the list of medications as these are indicative of significant medical conditions and may interfere with periodontal treatment.1 Supplements and recreational drugs should be considered as “medications” for their potential to interact with dental anesthesia and periodontal disease. Medications should be checked against a database (i.e., Lexicomp, Physician Desk Reference) and their typical use, mechanism of action, potential for drug interaction, and oral side effects researched. The following types of medications are relevant for periodontal treatment:
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Antidepressants (tricyclics and monoamine oxidase inhibitors) have severe hypertension risk with epinephrine.2
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Anti-HIV medications can have oral side effects such as xerostomia and gingiva discolorations. Anti-HIV medications tend to have renal toxicity, and NSAIDs should be avoided.
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Anticoagulants pose bleeding risks during invasive procedures.3 Consult with a physician to lower bleeding risk or achieve an international normalized ratio (INR) target of less than 2.5 prior to surgery.
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Antiplatelet agents may pose bleeding risks during invasive procedures. Usually, bleeding risk is not significant, and medication should not be discontinued.4
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Beta-blockers and nonselective may produce orthostatic hypotension. Epinephrine may increase blood pressure while lowering pulse.
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Bisphosphonates use may pose a risk for osteonecrosis (0.1 to 4% for users of oral bisphosphonates, 10% after IV bisphosphonate administration) after periodontal surgery, scaling and root planing, or even the presence of periodontal disease.5
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Calcium channel blockers are associated with gingival enlargement (<10% of users).
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Calcium supplements interfere with tetracyclines (i.e., doxycycline).
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Corticosteroids lead to infection and adrenal crisis risk. Consult with the physician and consider doubling corticosteroid dose on the day of the procedure, along with antibiotic prophylaxis.
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Cyclosporine lead togingival enlargement (up to 60% with cyclosporine; less with sirolimus and tacrolimus) and postoperative infection risk. Consider antibiotic prophylaxis.
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Deferiprone (an iron chelator) may cause neutropenia and sever periodontal disease.
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Dilantin/phenytoin results in gingival enlargement (40% of users).
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Estrogen replacement/birth control results in enhanced gingival inflammation. It may be associated with pyogenic granuloma.
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Methotrexate and immunosuppressive medications lead to postoperative infection risk. Consider antibiotic prophylaxis.
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NSAIDs lead to occasional bleeding risk. They are associated with lichenoid lesions and renal toxicity.
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Phenobarbital is infrequently associated with gingival overgrowth.
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Supplements such as garlic, gingko, ginger, chamomile, vitamin E, and large doses (several grams) of fish oil supplements may pose a bleeding risk.
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Thyroid hormone replacement (i.e., Synthroid) may cause possible hypertension risk with epinephrine. It is occasionally associated with bleeding risk from acquired von Willebrand disease.
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Valproic acid is infrequently associated with gingiva overgrowth.
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Xerostomic medications: There are over 400 medications that are associated with xerostomia, which is associated with both increased caries and periodontal disease risk.
Medical History/Review of Systems
Medical conditions are of interest for periodontal treatment since they either present a treatment risk or interact with periodontal disease. Consequently, periodontal assessment requires a thorough medical history and review of systems.
Generally, medical conditions present the following five types of concerns for periodontal treatment:
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Need for antibiotic prophylaxis for periodontal exams: Bacteremia caused by periodontal probing may pose a risk of serious infection for patients with some medical conditions, typically conditions linked to bacterial endocarditis6 or the presence of implanted medical devices such as total joint replacements,7 catheters, ports, stents, and vena cava filters. Usually, this requires consultation with the patient’s physician, and a dose of antibiotics (2-g amoxicillin or 600-mg clindamycin) may need to be prescribed 1 hour before the periodontal exam.
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Need for antibiotics to prevent postoperative infections after invasive treatments: Periodontal procedures such as scaling and surgery introduce bacteria into oral tissues and cause bacteremia. This creates a risk of postoperative infections for patients with weakened immune responses, in addition to patients with implanted medical devices or at risk for bacterial endocarditis. Generally, consultation with the patient’s physician can assist in judging the risk of infection and prescription of antibiotics either for the procedure or afterward should be considered.
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Risk of medical emergencies during dental procedures: Periodontal procedures may be lengthy, stressful, and uncomfortable for patients and often require the administration of local anesthesia. This increases the risk of medical emergencies occurring during treatment. For patient’s safety, it is important to identify conditions that pose a risk for medical emergencies, and be prepared to address these emergencies if they arise.8
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Treatment modifications needed: For some medical conditions, adjusting the way treatment is delivered may improve patient comfort or lessen the risk of medical emergencies.
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Periodontal-systemic relationships: Some medical conditions influence periodontal disease and vice versa. These may exacerbate periodontal disease or lessen the chance of treatment success. Periodontal disease treatment may also aid in improving medical conditions, and knowledge of these relationships can motivate some patients for periodontal treatment.
The medical conditions that are a concern for periodontal treatment are listed in (Table 2.2a-b).
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