Introduction

Periodontology is the art and science of maintaining the health of the tissues which support teeth and dental implants. It is not only critical to oral health, but also to general health and wellbeing.

Periodontal disease is a chronic problem. Initial therapy is often carried out simultaneously with other forms of dental treatment. The management will extend throughout a patient’s life and will often be dependent for success on good patient compliance and thorough careful maintenance therapy by dental professionals. This should be continued even after successful completion of definitive restorative treatment (Figure 18.1).

Oral Hygiene Techniques

Brushing

Toothbrushing is still the most important method of plaque removal available but it will not remove plaque from fissures or the normal interdental area.

Brush Design

• Material: the preferred material is nylon. Nylon stiffness is more easily controlled because the diameter is more uniform.
• Design: toothbrushes are now produced in many designs. There is little clinical evidence to suggest the superiority of any one shape. Historically, it has always been suggested that the head should be trimmed flat and level and be multi‐tufted, all tufts being of the same length. Serrated trim does not appear to be more effective. The ends of the filaments should be rounded.
• Length of head: most patients find a short head more suitable, but in clinical trials it is no more effective than a long head. A smaller head improves access to areas of the oral cavity. Larger brush heads are more difficult to manoeuvre in posterior areas. A length of 2.5 cm for adults and 1.5 cm for children is recommended.
• Stiffness: there is some conflict between the results of various tests on the plaque‐removing ability of the different grades. It is generally recommended that patients use a soft–medium strength for adequate plaque removal. Hard bristles are not recommended as they may cause tooth abrasion especially where recession is present.

Frequency

Brushing twice a day is recommended and the most important time is at night, just before going to bed. This is an effective way of establishing a good oral hygiene routine.

Duration

There is a great individual variation in speed and efficiency. The criterion is to brush until all plaque is removed. A general rule is to brush for a minimum of 2 min, ideally 3 min to clean all surfaces effectively. Evidence indicates that patients rarely brush for this length of time and often spend less than 60 s.

Systematic Coverage

Brushing should be carried out in a systematic manner to ensure all surfaces are cleaned. Research shows that patients tend to spend longer brushing buccal surfaces. Far less emphasis is placed on cleaning the lingual and palatal surfaces of the teeth.

Techniques

A patient’s brushing method should not be altered unless there is evidence of inefficiency or of damage to the tissues. If the plaque is removed without tissue damage, then the method is correct.

Basically, there are two movements: sweeping and penetrating. A reversal of direction of motion of the brush whilst under pressure results in a penetrating movement. Some penetration into the embrasures is always essential: penetration into the gingival crevice is also necessary on occasions. Many different techniques are described in the literature, but as stated above, if the plaque is removed then the technique is correct.

Modified Bass Technique 

The Modified Bass technique is the most widely accepted and used brushing technique. This method of brushing requires the tufts to be pointed apically at about 45 degrees and the ends pressed against the tooth and gingival margin to bring about adaption of the filaments to the complicated teeth–gum embrasures (Figure 18.2). The objective is to penetrate the gingival crevice. The brush is then vibrated or moved in small circles (mini scrub) so that the ends of the filaments move a little in relation to the adjacent surfaces. Because of the flexibility of the filaments, the amount of movement at their ends is relatively small compared with the movement of the brush. The brush is then moved to another place, but it need not be lifted from the teeth to do this. The patient should count the number of strokes on each surface to ensure sufficient time is dedicated to plaque removal.

Other Brushing Techniques

• Horizontal/scrub (mixed – sweeping, partly penetrating).
• Roll technique (sweeping).
• Charters (penetrating).
• Stillman (penetrating).

Manual Toothbrushing: Common Errors

• Not spending enough time or not brushing frequently enough.
• Leaving areas untouched – often lingual and palatal areas, because are they are difficult to access and cannot be seen.
• Applying excessive pressure that may cause the tufts to become distorted and cause tooth surface abrasion.
• Not applying bristles to the gingival margin.

Toothbrush replacement is recommended every 3 months, or sooner if the filaments lose their shape. This is referred to as splaying. Splayed filaments are ineffective, possibly damaging to the soft tissues and harbour bacteria.

Electric Toothbrushes

Electric toothbrushes provide limited benefit over a correctly used manual toothbrush, but there are added benefits for those with reduced manual dexterity. This group includes the elderly, physically disabled and those with arthritis in their hands and wrists. Care providers may also find electric toothbrushes easier to handle. Electric brushes can also be recommended to non‐compliant patients, as they are perceived as easier and faster than manual and may have a motivational element.

They are available in rechargeable and battery‐operated varieties. The battery option can be cheaper, but possibly not as effective as the battery loses power and the brush gradually runs at a slower speed.

The correct electric brushing technique must be demonstrated to the patient, as it differs from the manual technique. It is important that the patient places the brush at the gingival margin for 3–5 s on each surface, and let the brush do the work. It helps with concentration if the patient counts the number of seconds spent on each site. The brush must not be moved as if it were a manual brush as this reduces its effectiveness. Patients should be advised to charge electric toothbrushes often (alternate days) and to replace brush heads every 3 months, or sooner if the bristles splay.

Electric toothbrushes have two modes of action.

Oscillating – Rotating

• The brush head utilises a side to side and rotating mechanical movement.
• Many brushes also pulsate with an in–out action to loosen the plaque, then oscillate to whisk it away.
• 7600 – 8800 rotations, 20 000 – 40 000 pulsations per minute.
• A variety of heads are available for different needs – interspace, orthodontic, flossing, tongue cleaner, whitening.

Sonic – Vibrating

• The brush head utilises a sweeping movement combined with high speed sonic vibrations.
• 21 000 – 31 000 vibrations per minute.
• Fluid forces created by the vibrations whip toothpaste and saliva into an oxygen‐rich foamy cleanser, which removes plaque combined with the high‐speed brushing action.
• Some patients may not tolerate the vibratory action of the brush.

Interdental Plaque Removal

Flossing

Floss is available in waxed or unwaxed versions. Waxed is said to be easier to use, if tight contacts exist between the teeth. In practice, there is little to choose between the two. It should be used in a vertical direction only and it is not advised in young patients. It may be used in conjunction with floss holders. Floss made of PTFE slides very easily between tight contacts. Patient adherence to flossing can be difficult to achieve as the technique is difficult to master and is perceived as time‐consuming and arduous. Effective flossing requires excellent manual dexterity.

Dental Tape

Dental tape is like floss only wider. It is useful for cleaning, for example, bridge pontics and any tooth with adjacent gaps.

Specialised Floss

Superfloss is described as three flosses in one. It is marketed for use in patients with crowns, orthodontic appliances and bridgework. It has a stiffened end to thread between the teeth, a spongy portion to disrupt biofilm under pontics and fixed prostheses, under bridge pontics and around implants, and a floss section to clean in between other dentition.

Flossing Technique (Figure 18.3)

• Dispense 40 cm of floss.
• Wrap ends around middle fingers.
• Leave 10 cm in between hands.
• Use index fingers and thumbs to guide floss.
• Look in a mirror.
• Gentle side‐to‐side motion to get between contact point, taking care to avoid trauma or discomfort.
• Gently slide floss down the side of tooth into the sulcus.
• Applying pressure against the tooth, press floss from buccal and lingual aspects in a ‘C’ shape around the tooth.
• Keep pressure and contact with the tooth and move in a coronal direction removing plaque as you go.
• Insert floss back into the same space and repeat sequence on adjacent tooth.

Other Interdental Aids

Interdental Brushes

These are small brushes like bottlebrushes (Figure 18.4). They are available in many widths with either cylindrical or cone‐shaped heads. They can be handheld, e.g. mini‐interdental, or fitted into a handle. They are used to clean most interdental areas and wider spaces such as the interdental embrasures created postsurgically or small gaps occurring in tilted or irregular teeth. They are most suitable for patients with moderate to advanced periodontal destruction as they remove more plaque from large spaces when compared with floss. The brush dimension is selected based on the size of the interdental space and root morphology.

Single Tufted Brushes

Single tuft type brushes are manufactured with either a flat trim tuft or a pointed tuft (Figure 18.5). Single tufted brushes are used for plaque removal in furcation areas, around lone‐standing teeth and areas of localised gingival recession. The monotip in Figure 18.5 may be adapted by simply bending the handle to the desired angulation. It is also recommended for use around single implant abutments and implant‐supported prostheses.

Other Oral Hygiene Adjuncts

Chlorhexidine Gluconate

This can be used as a chemical adjunct for patients requiring treatment of acute gingival inflammation. It is available in mouth rinse and gel and considered the gold standard due to its robust substantivity. It is a bisbiguanide and has bacteriocidal and fungicidal properties. It is considered to be most effective in patients postsurgery or where oral hygiene measures are compromised. It decreases pellicle formation and alters bacterial attachment to tooth surfaces. The general advice is to use for a 2‐week period and then cease usage. It is important to delay the use of dentifrices containing sodium lauryl sulphate after rinsing with chlorhexidine as it interferes with the plaque inhibition action. It is not suitable for widespread use but is helpful in the management of medically compromised patients who are predisposed to oral infection. It has side‐effects such as staining and altered sense of taste hence long‐term use is not recommended.

The WaterPik

This and other irrigation devices have not been shown to remove plaque and any improvement in the gingival tissues which occurs when they are used may be associated with the increased patient interest in oral hygiene which they produce. However, they may be of use in dislodging food debris from under bridge pontics as an adjunct to daily brushing and interdental cleaning.

Wood Points

They do not remove plaque but can be used to dislodge food debris. Patients who use wood points should be advised to change to the appropriate size interdental brush to remove plaque and food debris and, in turn, improve periodontal health.

Behavioural and Systemic Secondary Factors

The management of periodontal disease revolves around:

• Achieving good oral hygiene and patient concordance and attending professional intervention at agreed intervals.
• Accounting for, and wherever possible controlling or eliminating, other systemic or behavioural factors which have an adverse effect on periodontal health. There are a range of conditions and situations which may adversely affect treatment outcomes.

Smoking Cessation

Tobacco use has a detrimental effect on the periodontium. It is one of the most significant risk factors in the development and progression of periodontal disease. Smokers are more likely to present with periodontal destruction when compared with non‐smokers and the increased risk of periodontal disease is around six times higher. Studies show that smokers tend to have a poorer response to periodontal treatment despite good plaque control. Studies have also shown that smokers spend less time on oral hygiene measures than non‐smokers and therefore have more plaque and calculus. Clinical signs may also be masked in smokers and gingival bleeding is often reduced. This is a result of vasoconstriction of the blood vessels and increased keratinisation common in smokers. Smoking cessation should be included in all treatment planning and clinicians should take an active role in implementing this in the management of every patient. Clinicians should offer advice and support and educate about the effects of smoking on the periodontium and treatment outcomes. Research has shown that patients who stop smoking will show a marked improvement in their periodontal status within 3 years of quitting.

Management of smokers should include:

• Taking a detailed smoking history.
• Educating about the effects of smoking on the periodontal tissues.
• Advising about the impact of continuing to smoke on treatment outcomes.
• Establishing if the patient is ready to quit smoking.
• Setting achievable goals for subsequent visits.
• Referral to a ‘stop smoking service’.
• Being supportive and non‐judgemental.
• Educating the patient on plaque control, diet and caries.
• Delaying complex treatment until the patient has reduced or quit smoking.

Diabetic Control

Periodontal disease develops more quickly, at a younger age, and to a more severe level and a wider extent in people who have diabetes that is poorly controlled. Poor metabolic control can impact on host responses in the periodontium. This association is not general knowledge amongst all branches of the medical profession, and it may be very important for the dental practitioner to inform and liaise with the patient’s general medical practitioner and specialist metabolic team. Periodontal treatment is more successful if diabetic status is well controlled, indicated by a favourable glycosylated haemoglobin score (HbA1C) of 7.5% or less, and complex procedures are only advised where control is good. Active periodontal disease may have a big enough systemic inflammatory effect to in turn compromise ease of diabetic control, in the same way as other infections elsewhere in the body may.

Such individuals should be examined and assessed as for any other case. However, management of the diabetic patient requires special care:

• Letter to medical team and general medical practitioner: the dentist should contact the medical team involved with the patient, to determine how well controlled the patient is and if there are any other associated issues.
• The role of diabetes in the aetiology and progression of gum disease should be discussed at the first consultation, and the importance of good control stressed as an integral part of the management of gum disease. An indication of the patient’s diabetic control should be obtained (and of their own awareness of their status) by enquiring as to their most recent test results, in terms of exact results, and targets that they are expected to achieve. This can be verified with the medical team.
• It is wise to check the status of diabetic control at every appointment. This emphasises the importance of this factor and ensures that the dentists can relate clinical changes to metabolic influences.

Impact of Other Systemic Factors

Infectious Disease

The use of universal cross‐infection control procedures should mean that infectious diseases should have limited specific effects on periodontal procedures. However, patients with advanced HIV disease may present with necrotising periodontal diseases. These can be simply managed by non‐surgical care as outlined below, but may require the use of adjunctive systemic metronidazole or antimicrobial mouthwashes containing chlorhexidine or povidone‐iodine.

Allergy

There are no unique issues related to periodontology that have any greater impacts than for other aspects of operative dentistry. Agents potentially initiating allergic responses would most likely be gloves, local anaesthetics, and systemic and local antimicrobial agents. Allergies to components of toothpastes, mouthwashes and prophylaxis pastes such as detergents and flavourings have been reported, and these can be confirmed by specialised patch testing in suitably controlled hospital environments.

Mucosal Disease

A range of mucosal diseases may involve gingival and periodontal tissues. These may range from benign lesions to those resulting in severe local tissue damage and inflammation. Such changes can make oral hygiene very difficult for patients, with a corresponding increase in the frequency of maintenance care to achieve periodontal stability. Lesions may make mechanical oral hygiene very uncomfortable, and commonly used antimicrobial preparations such as mouthwashes may not be viable in their marketed forms due to extreme burning and other discomfort experienced by patients. It may be necessary to dilute these products with water before use, although this may have a corresponding adverse effect on their antimicrobial effectiveness.

Interactions With and Effects of Other Therapeutic Interventions

Anticoagulants

Anticoagulants may lead to prolonged delayed bleeding after periodontal surgery and occasionally after root surface instrumentation. Patients should be warned of this risk before treatment and appropriate advice given in advance. Routine guidance for surgery in patients taking anticoagulants applies, with an increased need for use of topical antifibrinolytic agents such as tranexamic acid mouthwashes where local measures are unlikely to be effective.

Bisphosphonates

Biphosphonates are widely used for a range of conditions ranging from osteoporosis to secondary bony malignancy, in varying doses and means of administration. All surgery, including periodontal surgery, should be performed with caution, although it appears that the risk of complications is lower with oral compared with intravenous medication.

Cardiac Surgery

Although there has been a shift in guidelines against antimicrobial prophylaxis for dental procedures, the advent of some modern devices such as the Amplatzer occluder (an umbrella shaped device delivered from within a vessel and opened up at placement within the heart for the closure of septal defects) may still require the dentist to liaise with cardiac surgeons and ensure that treatment is either delayed or associated with antimicrobial use for the time period before such devices are fully covered by endothelial cells after placement.

Contraceptive Pill

It has been suggested that long‐term use of oral contraceptives may result in increased marginal bone loss. However, this has not been overwhelmingly confirmed and much data relates to older, higher dose versions of these therapies – similar effects may not occur with more modern regimes.

Radiotherapy

Patients undergoing radiotherapy may experience discomfort from oral mucositis, which may make oral hygiene procedures painful and difficult. This may require increased professional maintenance care during the active treatment phase. Whilst chemical antimicrobial adjuncts may be helpful, these may also be uncomfortable to use. Radiotherapy may have two long‐term impacts on periodontal care. Firstly, there may be compromised local healing and an increased risk of osteoradionecrosis after surgery, especially if bone removal is carried out. Secondly, radiotherapy to the head and neck may result in xerostomia and associated increased plaque formation and marginal inflammation. There are minimal data associating xerostomia with marginal bone loss. In addition, the clinician must be aware of the possibility of secondary tumours presenting within gingival tissues: in cases of uncertainty it is wise to consider biopsy of suspicious lesions, in conjunction with specialists if needed.

Drug‐Induced Gingival Enlargement

Various groups of drugs have been implicated as having a role in the aetiology of this problem. These include calcium channel blocking antihypertensives such as amlodipine, phenytoin (anticonvulsant) and ciclosporin (used as an immunosuppressant and often in conjunction with antihypertensives). These are best managed by provision of periodontal therapy and good oral hygiene techniques before commencing medication, but many patients may start these drugs with suboptimal oral health. This can result in the need for further treatment. After treatment, these individuals should receive more frequent and comprehensive maintenance care. Management options include:

• Change medication: it is sometimes possible to arrange for the patient’s general practitioners to change the problematic medication, especially if it is impairing appearance or oral health and impacting on quality of life. The dentist should correspond with medical colleagues.
• Non‐surgical treatment: although enlarged gingival tissues may become quite fibrotic, it is possible to achieve some degree of resolution by non‐surgical therapy, although this may need to be repeated several times to allow adequate time for a favourable tissue response, ideally in conjunction with a change in medication.
• Surgical treatment: failure of tissues to completely shrink after non‐surgical treatment, or presentation with extreme tissue enlargement, may require a surgical approach, as outlined below.

Orthodontics

Pre‐existing periodontal disease, and associated tooth movement, does not preclude subsequent orthodontics. It is important to establish periodontal health and good oral hygiene practices before commencing any orthodontic treatment. Failure to do this may result not only in an exacerbation of existing periodontal pathology but also increase the likelihood of enamel demineralisation and frank caries lesions. Orthodontic treatment would not proceed unless the patient can demonstrate good oral health with corresponding reductions in gingival inflammation, bleeding and pocket depths.

Maintenance therapy should be continued during orthodontic treatment. In the presence of fixed appliances good oral hygiene is even more difficult to achieve, and if the patient is periodontally susceptible, consideration should be given to running concurrent hygiene appointments with each orthodontic appointment.

Orthodontic treatment may lead to localised gingival recession, especially where the soft tissues are thin and teeth are moved labially out of the alveolar envelope. This is most likely if treatment has included arch expansion to create space. These problems can be managed, on completion of orthodontics, by mucogingival and grafting procedures.

Treatment Planning for Therapy

Patient History

Treatment planning relies on taking an accurate and appropriate history, as outlined in Chapter 6 of this manual. Special emphasis should be placed on:

• What are the patient’s perceived problems and concerns?
• What do they want to achieve from treatment?
• Previous dental and periodontal treatment: what was done, when and by whom? Was local anaesthesia used?
• Causes and timing of previous tooth loss.
• Current oral hygiene practices.
• Potential risk factors.
• Family history of periodontal problems and early tooth loss.

This should be accompanied by a full restorative assessment, including special tests. Periodontal problems rarely occur in isolation and treatment often has other restorative implications.

Non‐surgical periodontal treatment is generally carried out as part of first phase dental treatment, after pain relief, but as part of disease stabilisation before considering definitive restorative options. This may be in conjunction with extractions and provisional prostheses, with splinting of mobile teeth and possibly even use of failing teeth as provisional bridges after sectioning and root removal.

Periodontal treatment planning must consider the prognosis of teeth in terms of restorative and periodontal features. In addition, the value of teeth as potential long‐term abutments should be considered, together with the impact of tooth retention on aesthetics, function and quality of life. This varies between individuals – some patients would rather have a predictable stable long‐term solution involving a greater number of extractions, but others may prefer to retain as many teeth for as long as possible and accept some degree of mobility and aesthetic compromise. These decisions can only be made after a careful discussion with the patient and development of an understanding of their perceived problem and aims of treatment, in both the short‐ and longer term.

Diagnosis – Assessment and Reassessment

Diagnostic procedures include all routine clinical assessments common to all patients, as outlined in detail elsewhere. These may be carried out in the following order:

• Assessment of all mucosal and soft tissue surfaces.
• Awareness of pathology of gingival tissues: swelling, colour, consistency, epithelial integrity, tenderness, sinuses, abscesses, gingival recession.
• Restorative assessment: restorations, caries, fractures and cracks, endodontic status.

Periodontal Assessment

Routine periodontal screening involves the basic periodontal examination (BPE) using a WHO periodontal probe (Figure 18.6). This probe has a 0.5 mm diameter ball‐shaped tip then a narrow shaft marked with a black band between 3.5 and 5.5 mm from the probe tip, and is used with an applied load of less than 25 g. This probe configuration is labelled CPITN‐C if it has an additional black band between 8.5 and 11.5 mm, and is labelled CPITN‐E if the second band is absent.

The assessment is carried out around all teeth, but summary scores are made for each sextant. The sextants contain either molars and premolars, or the canines and incisors. Each sextant must have at least two functioning teeth – if only one tooth is present it should be incorporated into the adjacent sextant.

Each sextant is scored with the worst tooth score for that sextant. These are defined as:

• Score 0: there are no pockets exceeding 3 mm (coloured band on probe is fully visible), no calculus or restoration overhangs present and no bleeding after probing.
• Score 1: there are no pockets exceeding 3 mm, no calculus or restoration overhangs present but bleeding is seen after probing.
• Score 2: there are no pockets exceeding 3 mm, but calculus, restoration overhangs or other local plaque retentive features are identified.
• Score 3: coloured area of probe is only partly visible (probing depth greater than 3 mm but less than 6 mm).
• Score 4: coloured area of probe is not visible (probing depth greater than 6 mm).

Score *: attachment loss of 7 + mm or furcation involvement present.

A patient with sextants scoring 4 or * should be investigated further.

Complete periodontal assessment is likely to be needed in the case of:

• A BPE score of (possibly 3), 4 or *.
• As part of treatment planning for multidisciplinary restorative cases, or as a precursor to implant or adult orthodontic treatment, especially if the patient has a history of periodontitis.

Complete assessment includes, in addition to those procedures outlined above:

• Six‐point assessment of probing depth and attachment level, as well as bleeding on probing.
• Clinical assessment of furcation involvement.
• Assessment of tooth mobility.
• Assessment of occlusion.
• Further detailed assessment of gingival recession may be required in some cases, for instance advanced gingival recession.
• Assessment of oral hygiene.

Six‐Point Probing/Bleeding/Recession Assessment 

Probes: the preferred probes for full pocket charting are one of the following:

• Williams probe: this blunt ended straight probe should have a diameter of around 0.5–0.7 mm and should have clear graduations scored and marked at 1, 2, 3, 5, 7, 8, 9 and 10 mm from the tip (Figure 18.7).
• UNC‐15 probe: this blunt‐ended straight probe should have a diameter of around 0.5–0.7 mm and should have clear graduations scored and marked every 1 mm, but with the spaces between 4 and 5 mm, 9 and 10 mm, and 14 and 15 mm marked as black bands (Figure 18.8).

Both probes are used in an identical manner, inserted gently into the pocket with a maximum load equivalent to 15 g, in a direction as parallel to the root surface as possible.

Probing method:

• Confirm which teeth are present with recording staff. Include implants.
• Agree location of starting point for charting procedure, e.g. distobuccal upper right last standing tooth. This may be determined by software package being used locally for recording clinical data digitally.
• Start charting, proceeding around arch towards midline (e.g. mesiobuccal upper right central incisor).
• On reaching midline, confirm this location with assistant to minimise risk or charting error. Then check back along previously probed sites and record presence/absence of bleeding at each.
• Continue around arch from midline, recording probing depths, and at end of arch (e.g. distobuccal upper left last standing tooth). Recheck these areas for bleeding.
• Repeat for other side of this quadrant.

Following assessment of probing depths and bleeding, gingival recession should be recorded in the same manner. This can be simply done using the periodontal probe to measure the distance in millimetres between the amelodentinal junction and the marginal gingiva. The presence of cervical restorations may make this difficult, and if no clear landmarks are present it may be wise to use the existing restoration margin for consistency over time.

The more sophisticated Miller classification for recession assessment is generally used as part of a periodontal or restorative assessment where gingival recession and/or aesthetics are possible issues, and where surgery is considered as a potential treatment option.

• Class 1: marginal tissue recession which does not extend to the mucogingival junction; no periodontal bone loss in the interdental area (Figure 18.9).
• Class 2: marginal tissue recession which extends to or beyond the mucogingival junction; no periodontal loss in the interdental area (Figure 18.10).
• Class 3: marginal tissue recession which extends to or beyond the mucogingival junction, bone or soft tissue loss in the interdental area or malpositioning of the teeth, preventing full root coverage (Figure 18.11).
• Class 4: marginal tissue recession which extends to or beyond the mucogingival junction, severe bone or soft tissue loss in the interdental area and/or malpositioning of teeth (Figure 18.12).

Furcations and Assessment of Disease Around Multirooted Teeth 

Furcations can be assessed using a routine periodontal probe, but the local anatomy can often make it difficult to accurately assess furcation involvements in this way. In such a case a Naber’s furcation probe is helpful. This double‐ended probe has curved ends designed to enter furcations more readily, especially for upper molars. This assessment is carried out following probing depth and recession measurement.

Furcations are graded as:

• Grade 1: horizontal loss of tissue less than one‐third of tooth width.
• Grade 2: horizontal loss of tissue more than one‐third of tooth width but not extending the full tooth width
• Grade 3: horizontal loss of tissue extending the full tooth width ‘through and through’.

There is also an optional Grade 4 classification, which refers to a through and through furcation where the furcation is open and accessible. In this system, a Grade 3 classification refers to a through and through furcation where the entrances are covered by marginal soft tissue but there is complete attachment loss.

Mobility Assessment 

Tooth mobility can have a variety of causes and it is important to identify and quantify mobility. This is normally achieved by attempting to move the tooth from side to side (normally buccolingually) and vertically, using either one to two single‐ended instruments (i.e., mirror and probe) handles.

Mobility is graded:

• Grade 1: more than normal physiological tooth mobility (0.2 mm) but less than 1 mm movement in a horizontal direction.
• Grade 2: more than 1 mm movement in a horizontal direction but no vertical movement.
• Grade 3: vertical and horizontal tooth movement.

Oral Hygiene Assessment 

Oral hygiene can be assessed using a visible plaque score. However, this does not allow a tailored and detailed approach to oral hygiene instruction which has the best chance of achieving the optimal result. Oral hygiene scores are best left until after clinical examination, including probing, if disclosing agents are to be used, as they can change the appearance of marginal tissues.

The use of disclosing solutions is the preferred way of obtaining an accurate assessment of oral hygiene (Figure 18.13). There are several ways that this can be done. However, the use of disclosing solutions can be misleading in the presence of extrinsic staining and calcified deposits. It is most useful to assess ongoing oral hygiene after gross scaling to remove such deposits.

Disclosed plaque scoring methods include some very specialised techniques designed to identify small changes in the rate of plaque formation, and low levels of plaque formation. These are largely used in clinical research – whilst they are detailed, they are generally not practical for day‐to‐day practice.

A more practical approach is to use a four‐point or six‐point assessment of each tooth present, and to record the presence or absence of disclosed plaque at each site, generating a percentage plaque score (Figure 18.14).

Procedure:

• Explain nature and aim of procedure to patient. Confirm that it is likely that they may have some temporary staining of dorsum of tongue after procedure, and that this will not be a problem for them for the rest of the day.
• Apply Vaseline barrier to lips to minimise lip discolouration by disclosing agent.
• Apply disclosing solution to teeth. This may be either using a disclosing tablet, chewed by the patient (followed by a rinse), applied using cotton wool pledgets around the gingival margins of all teeth, or using special premanufactured application buds (Figure 18.15).
• Record the presence or absence of plaque at each site, and calculate the percentage of all sites with plaque present. Discuss with thee patient, and use the chart to identify areas/sites where oral hygiene is inadequate (e.g. proximal sites), with suitable targeted advice for improvement. Patients should be given targets to help them improve their homecare routine. Ideally plaque scores should be less than 10% but a realistic goal would be <25%.

Calculation:

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