The next step after periodontal data gathering is periodontal diagnosis, which means identification of a patient’s ongoing periodontal disease(s) and attempting to understand what factors led to a patient’s current periodontal condition. Identifying the patient’s ongoing disease(s) is necessary for documentation, treatment planning, billing, and insurance reimbursement. Having an understanding of a patient’s periodontal disease is critical to treatment planning, as missing a contributing factor to periodontal disease may cause treatment failure. This chapter will describe a thought process for approaching diagnosis, identifying common and uncommon periodontal diseases, ruling out periodontal disease as a cause of pain or lesions, and developing an etiology-based treatment plan.
Case
A 62-year old Caucasian female presented to the clinic for a “check-up.” She used to see a dentist regularly up to 2 years ago, when crowns were made, but moved to this area recently and wanted to see if everything was still all right. She did not report any immediate concerns, but did report that her gums bled when she flosses and that some teeth are slightly sensitive when she bites down. She uses a medium toothbrush twice a day and does not floss since it makes her gums bleed.
She felt “healthy” and checked off “gastroesophageal reflux disease (GERD)” on the medical history form. When questioned, she reported taking 40-mg Omeprazole once daily for it which rendered her free of symptoms. She also takes 10-mg Simvastatin once a day and 500-mg naproxen occasionally for occasional headaches or muscle pain from her arthritis in her knee and hand joints. She reports having her gall bladder removed 4 years ago because of a “cyst,” and that she used to smoke tobacco for 40 years (about 3 packs/week) before quitting it 5 years ago. She also used to drink alcoholic beverages daily, but quit about 10 years ago. She is 5’0” tall and weighs 160 lbs. Her blood pressure is 138/87 mm Hg, pulse is 77/min, and respiration 15 breaths/min.
Extraorally, there were no findings other than fair facial skin that exhibits signs of aging. Temporomandibular joints function normally with no pain and normal open range. Salivary glands are shaped normally, but flow seems to be reduced. Oral mucosal surfaces appear normal other than patches of marginal and papillary erythema such as between teeth nos. 24 and 25. Teeth nos. 5, 9, 11, 12, 21, 23, and 29 have wear facets, and there was an interference between tooth no. 5 distal ridge and tooth no. 29 mesial ridge, that produced a corrective slide into centric occlusion. At the same time, tooth no. 29 appeared to move slightly at occlusal contact, but the fremitus could not be confirmed with light palpation. Teeth are in Angle Class I relationship with about 3-mm overjet and overbite.
Periodontal exam findings revealed numerous deep pockets, generalized bleeding on probing (BOP), attachment loss, and multiple teeth with facial recession. At each tooth, plaque was found in a thin rim of plaque at the gingival margin, and subgingival calculus was found on most interproximal and lingual surfaces. Multiple teeth had caries and there was minor tooth mobility on teeth nos. 6, 24, 29, and 32. The clinical appearance (Fig. 3.1) and radiographs (Fig. 3.2) are shown in these figures.
Findings in the periodontal chart are as follows:
What can be learned from this case?
As discussed in Chapter 2, a patient seeking a “check-up” may have significant dental problems that accumulated since the last period of dental care, as shown in this case.
The most significant information for periodontal diagnosis has been summarized (see Table 3.2).
Periodontal diseases fall along a spectrum of disease exhibiting a spectrum of inflammation from none (healthy) to most severe leading to tissue die-off, purely local diseases affecting a tooth to systemic illness, superficial disease affecting gingiva to deep bone involvement, and modified by a myriad of microbial, systemic and local factors. Based on the clinical findings, this patient’s periodontal disease falls clearly in the middle spectrum of periodontal diseases, neither healthy nor extremely severe. Based on the current International Workshop definitions, this patient’s periodontal disease fits the diagnosis of periodontitis, stage III, and grade B.
While naming the disease is important for documentation and treatment justification, the real diagnostic work for most patients is to determine the factors that lead to the disease so that an effective treatment plan can be created. In this case, the factors contributing to the patient’s periodontal disease are:
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Decreased dexterity: The patient reports arthritis in her hands, which would interfere with efficient oral hygiene.
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Obesity: The patient’s body mass index (BMI) suggests obesity. This must be verified by physical observation. Obesity is associated with more severe periodontitis.
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The patient’s past tobacco and alcohol use may have made periodontal disease more severe in the past, but is no longer an active contributor.
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Plaque has been recorded on most teeth. Plaque is the clinical sign of microbial colonization of tooth surfaces, and needs to be treated in order to control gingival inflammation.
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Calculus is visible on lingual surfaces of mandibular incisors and radiographically on posterior teeth, and presents a plaque-retentive surface that the patient cannot clean.
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Caries presents a source of bacterial irritants and a rough, non-cleansable surface on many teeth:
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Nonrestorable teeth nos. 31 and 32: Heavily restored; have defective restorations exceeding the past furcation level. This, along with poor crown-to-root ratio, makes restoration unlikely.
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Food impaction is possible as there are many open contacts and diastemas, but the patient did not report “food getting stuck.” Given the uncertainty of food impaction, it is unknown how much it may have played a role in development of the periodontal disease seen at tooth no. 29.
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Open margins at teeth nos. 13 and 14: Open margins retain plaque, cause gingival inflammation, and are associated with an increased bone loss in this case, as seen at tooth.
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Biologic width impingement is possible at no. 4: Crown is close to apical crest, and there is some local bone loss.
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Multiple deep pockets, mostly in the posterior region and generalized BOP.
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Slight tooth mobility at tooth no. 6 is most likely related to occlusion as bone support is normal. Slight tooth mobility at teeth nos. 29 and 32 is due to severe loss of bone support.
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Gingival recession at teeth nos. 5, 6, 12, 21 and 23: Associated with abfractions, and also inflamed because of marginal plaque build-up.
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Tipping of no. 31 likely causes plaque retention in this area and may have contributed to furcation exposure.
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Mesial root concavities at teeth nos. 5 and 12 present plaque-retentive areas associated with pocketing.
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Wear facets, matching abfraction, and fremitus at tooth no. 29 suggest occlusal trauma.
The corresponding treatments for these contributing factors are as follows:
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Decreased dexterity: Oral hygiene instruction: use electronic toothbrush instead of a manual brush, preferably one with a wide handle. Consider using an electronic flosser (i.e., Hummingbird), and antiseptic mouthwash to reduce plaque levels.
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Calculus: Scaling and root planing in all quadrants, 4+ teeth.
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Caries: Crowns for teeth nos. 5, 6, and 18 for better interproximal contact and appearance.
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Biologic width impingement at tooth no. 4: Osseous surgery will solve the problem (see below).
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Deep pocketing/inflammation: If scaling and root planing is not effective, osseous surgery may be needed in all quadrants. A regenerative procedure may benefit tooth no. 29.
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Mobile teeth: Wait and see if mobility improves. Tooth no. 29 may need to be removed.
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Gingival recession at teeth nos. 5, 6, 12, 21, and 23: Connective tissue grafting.
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Tipping of teeth: Removal of teeth nos. 31 and 32 solves this problem.
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Root concavities at no. 5: Odontoplasty prior to restoration may make the tooth more cleansable.
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Occlusal trauma: Occlusal analysis and adjustment, limited where needed.
Missing teeth need to be replaced and the patient needs to be maintained:
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Missing teeth: Either removable partial dentures or implant-supported restorations, depending on the patient’s wishes and ability to commit to an expensive and long therapy.
Some patient factors that may affect treatment are as follows:
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Naproxen use: Although this medication may increase bleeding tendency, it is unlikely to be a risk in this case given the infrequent use.
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Hypertension: Long-term risk for stroke, heart disease, and dementia. Counsel patient to strive for lower blood pressure. Monitor prior to invasive treatment, and postpone treatment in case of severe, symptomatic hypertension.
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Atherosclerosis: Patient has long-term risk of in-office medical emergency.
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GERD: The patient may feel uncomfortable reclining in a supine position.
Identify Common Periodontal Diseases
After thorough assessment, the next step in periodontal treatment is periodontal diagnosis, the identification of the disease(s) present and identification of the factors that lead up to the disease(s). Periodontal diagnosis aids:
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Treatment planning as procedures are often tied to specific diseases and conditions.
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Prediction of future disease activity (prognosis), which determines long-term dental treatment.
The Six Dimensions of Periodontal Diseases
In order to prepare for periodontal diagnosis, consider data from the periodontal exam and organize the findings a long the following six dimensions that describe periodontal diseases:
In order to match a patient’s individual periodontal disease(s), consider summarizing the clinical data first along the following dimensions:
Severity of Inflammation
Periodontal inflammation fills a spectrum from pristine, healthy, pink, firm, and tight gingival margins over various levels of redness to rapid tissue die-off. Clinically, rate the worst level of inflammation seen at the gingival margin during the periodontal exam (Table 3.3).
Depth of Inflammation
The second dimension of periodontal disease is how deeply the tissue is damaged. Mild periodontal diseases affect only superficial tissues and are generally curable with no loss of tissue, whereas severe periodontal diseases cause lasting tissue damage including tooth loss. Based on clinical measurements, rate the depth of inflammation and tissue damage for the worst site along this spectrum (Table 3.4).
Consider if this is representative of the entire mouth, or if it reflects a unique local factor, such as a tooth fracture or failed root canal treatment. Also note if the depth of tissue damage is evenly distributed across all teeth, or is affecting few teeth or tooth types. For eventual disease grading, consider past loss in terms of the size of attachment loss over the last 5 years, or percent bone loss/year.
Extent of Inflammation
The third dimension of periodontal disease is the extent of inflammation, and subsequent tissue damage. While the generalized tissue damage is suggestive of mouth-wide local factors such as poor oral hygiene or systemic conditions (i.e., tobacco use), the localized tissue damage usually indicates a unique local factor that exacerbates periodontal disease. Analyze the pattern of deep pockets, attachment loss, or bone loss, and note if this affects only molars (excluding 3rds) and incisors. If it does not, calculate the percentage of teeth with attachment/bone loss to describe disease as localized or generalized (Table 3.5).
While the first three dimensions of periodontal disease mostly help in identifying the periodontal disease, the last three inform treatment planning and allow for grading the complexity of periodontal disease.
Microbiome
The fourth dimension of periodontal diseases is the make-up of the microbial community that makes up the disease. In most cases, no microbial testing is done and one has to subjectively judge the virulence of the microbial flora as shown below (Table 3.6 top row).
Microbial testing should be performed whenever there is attachment/bone loss that is much more severe than anticipated for a patient’s age and if there are no known local factors that could explain the observed disease activity. This usually includes:
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Children, adolescents, and adults under age 30 with significant attachment/bone loss.
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Adult patients who continue to experience attachment/bone loss despite competent periodontal treatment.
If microbial test results are available, the microbiome’s influence on disease activity can be rated as follows (Table 3.6 bottom row).
Systemic Factors
The fifth dimension of periodontal disease are the systemic background and possible contributing factors (see Table 3.7 for factors, and how they relate to periodontitis grading). As with microbial factors, for most patients, no specific test results will be available, and the systemic contribution to a patient’s periodontal disease needs to be estimated from the medical history.
Key factors to be recollected are:
If a patient’s severity of attachment/bone loss cannot be explained by the presence of local factors or unusual microbes and there is no known systemic factor that could explain the observed level of periodontal disease, the patient should be sent for a comprehensive physical exam.
Local Factors
The local factors that explain locally enhanced pockets, attachment loss, or bone loss comprise the sixth dimension of periodontal disease. Generally, factors that cause locally enhanced periodontal disease either favor plaque retention or induce chronic tissue trauma.
Case complexity and treatment difficulty increase with the number of complicating local factors (Table 3.8).
Everyday Periodontal Diagnosis
Even though many periodontal diseases exist, in day-to-day practice, identifying a patient’s periodontal disease means choosing from the following four choices:
If a patient presenting for an initial exam has not received periodontal treatment within the last year, the decision tree for diagnosis could be this (Fig. 3.3).
Fig. 3.3 Typical decision tree for diagnosis of common periodontal disease. BOP = significant bleeding on probing (>10% of sites). CAL = interdental clinical attachment level greater than zero, and explainable by the patient’s periodontal disease. RBL = radiographic bone loss, typically a distance greater than 2 mm between the cemento-enamel (CEJ) junction and alveolar bone crest.
Essentially, if there is no sign of significant BOP, the patient most likely has a form of periodontal health. If there is more than minimal BOP, the patient most likely either has periodontitis or gingivitis, depending on signs of attachment /bone loss attributable to periodontal disease in the presence of typical signs, symptoms, and medical history of common periodontal diseases. If the signs and symptoms are unusual for common periodontal disease (i.e., pain, tissue ulceration, not responsive to oral hygiene), or a medical condition is present that is associated with severe periodontal disease, the patient most likely has some periodontal disease other than periodontitis or gingivitis.
If a patient was seen recently for periodontal treatment, the patient may have achieved “periodontal disease remission” if recent treatment markedly improved BOP and pocketing. Alternatively, if signs and symptoms of periodontal disease have not changed much since the beginning of treatment, the patient still may have ongoing periodontal disease as diagnosed for untreated patients.
Health
Patients rarely present with periodontally healthy tissues during an initial exam, and this is the goal of periodontal treatment. There are four possible “healthy” outcomes in periodontal therapy (Table 3.9).1
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Pristine periodontal health: There is no sign of inflammation anywhere, and there is no evidence of past tissue damage in the form of increased pocketing, attachment loss, or bone loss. This is exceedingly rare.
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Clinical periodontal health: There is at most minimal inflammation (minor erythema or minimal BOP) and no evidence of deeper tissue damage such as pocketing, attachment loss, or bone loss.
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Periodontal disease stability (healthy, but reduced periodontium): There is, at most, minimal inflammation, but evidence of past disease activity in the form of attachment/bone loss.
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Periodontal disease remission (controlled periodontal disease): Treatment significantly reduced inflammation, depth, and extent of periodontal disease, but contributing local, microbial, or have not fully been controlled.
Clinical Relevance
Patients with clinical or pristine periodontal health have a low risk of periodontal disease, and treatment mostly consists of periodic evaluation every 6–12 months to ensure the absence of disease, and possible removal of any irritating factors.
Patients with periodontal disease stability and remission have a higher risk of disease recurrence and need frequent evaluation every 3–4 months (or sooner in the most high-risk cases) to check for disease progression and control factors that may re-initiate active disease.
Gingivitis
Gingival inflammation (gingivitis) is most often caused by dental plaque,2 and is the most common periodontal disease in otherwise healthy children, adolescents, and young adults. For the diagnosis of gingivitis,3 there must be significant BOP present, but no sign of attachment loss or radiographic bone loss that is attributable to the periodontal disease. Ulceration or severe pain is not a feature of gingivitis. Plaque-induced gingivitis resolves with control of plaque, and local and. Gingivitis can be modified by several medical conditions, and other gingival conditions such as pigmentation or enlargement can be present in addition to gingivitis as shown in Table 3.10. Gingivitis can be called localized if less than 30% of sites have BOP, and this may suggest a local contributing factor.
Attachment/bone loss can be present if caused by trauma (i.e., aggressive tooth brushing, tooth abfraction, and smokeless tobacco), orthodontic treatment, or malposition of teeth. In these conditions, bone and attachment loss is usually seen on the facial side of teeth in areas of gingival recession. Loss of teeth can also cause bone loss, gingival recession, and attachment loss on adjacent remaining teeth.
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