1. MEASURING PERIODONTAL DISEASE
CHAPTER 16
MEASURING PERIODONTAL DISEASE

2. GINGIVITIS
Often begins during early childhood, increases in prevalence and severity during adolescence, and then levels and becomes less severe in young adults
More than 50% of adults have gingivitis that affects an average of 3 to 4 teeth
Elderly do not appear to have higher prevalence than the rest of adult population
Males usually have higher levels of gingival inflammation than females, although a significant number of women experience more severe gingivitis during pregnancy

3. GINGIVITIS
African-Americans tend to have a higher prevalence of gingivitis than whites
Gingivitis may vary in severity at different sites in the mouth and show varying patterns of distribution within the mouth, depending on the presence and composition of bacterial plaque

4. CLASSIFICATIONS OF GINGIVITIS
1. ACUTE
2. CHRONIC
3. RECURRENT
4. LOCALIZED
5. GENERALIZED
6. PAPILLARY
7. MARGINAL
8. DIFFUSE

5. confined to a specific area of the oral cavity GENERALIZED GINGIVITIS
ACUTE GINGIVITIS
occurs suddenly and is associated with pain
short duration
CHRONIC GINGIVITIS
begins slowly
lasts a long time and is usually painless unless the tissues become secondarily infected
RECURRENT GINGIVITIS
returns following treatment or disappears spontaneously and then reappears
LOCALIZED GINGIVITIS
confined to a specific area of the oral cavity
GENERALIZED GINGIVITIS
involves the entire oral cavity

6. PAPILLARY GINGIVITIS
involves the interdental papilla and may extend onto adjacent marginal gingiva
most gingivitis develops first in the interdental papilla and then spreads to adjacent tissues
MARGINAL GINGIVITIS involves the gingival margins of the teeth in addition to the papilla and may also include a portion of attached gingiva
DIFFUSE GINGIVITIS
involves inflammation of all involved gingival tissues including papilla, marginal gingiva and attached gingiva

7. WHAT DO YOU SEE?

8. WHAT DO YOU SEE?

10. Recognize acute infections during the periodontal examination
Gather assessment information
Record significant findings in client’s record
Report findings in the diagnosis and treatment plan

11. GINGIVITIS 1. NECROTIZING GINGIVITIS
2. ACUTE HERPETIC GINGIVOSTOMATITIS
3. DESQUAMATIVE GINGIVITIS
4. PERICORONITIS
5. GINGIVAL ABCESS
6. PREGNANCY GINGIVITIS
7. PUBERTY GINGIVITIS
8. GINGIVAL HYPERPLASIA

12. ANUG ANUG TRENCH MOUTH VINCENT’S INFECTION VINCENT’S GINGIVOSTOMATITIS
NECROTIZING GINGIVITIS
Most prevalent in young adults (ages 15-30)
Predisposing factors: a)lowered host resistance b)acute emotional stress/anxiety
c) poor OH
S & S:
a) ulceration of marginal gingiva and interdental papilla - crater-like appearance (painful and bleeding)
b) grayish/yellowish “pseudomembrane”

13. ACUTE HERPETIC GINGIVOSTOMATITIS
Infection of oral tissues caused by herpes simplex virus
Most common in children under age 6 but also seen in older children and adults
Disease runs a course of 7-10 days (most acute 2-3 days)
S & S: a) diffuse redness of mucosa b) edema and gingival bleeding c) vesicles form initially and later rupture to form small painful ulcers

14. DESQUAMATIVE GINGIVITIS
Describes the gingival manifestations of a variety of systemic disturbances eg: lichen planus
Mild forms occur in girls and young women
S & S: a) diffuse redness (erythema) b) burning sensations and sensitivities to temperature changes - unable to tolerate spicy or rough-textured foods c) smooth and shiny tissues with patches of bright red and gray
d) surface epithelium may peel away from underlying tissues exposing raw, bleeding and extremely painful surfaces

15. PERICORNITIS
Localized gingivitis that occurs around partially erupted tooth
Gingival tissue overlying partially erupted crown is prime area for accumulation of bacterial plaque and food impaction
Nature of inflammation may be acute or chronic
S & S: swelling, redness, exudate, pain, tenderness of lymph nodes

17. GINGIVAL ABCESS
Localized, painful and rapidly progressing lesion that develops suddenly
Causes: a) toothbrush bristle b) sliver from toothpick c) popcorn husk d) seeds e) small fish bone/shellfishfragment
S & S: gingival tissue that is red, swollen, smooth, shiny and painful;localized pus (fistula)

18. GINGIVAL ABCESS

19. PREGNANCY GINGIVITIS
Change in hormonal balances and tissue metabolism during pregnancy can result in exaggerated responses of gingival tissue to local irritants and plaque
S & S: a) gingival enlargement/redness b) bleeding upon probing/spontaneous c) pregnancy tumor

20. PREGNANCY TUMOR

21. PUBERTY GINGIVITIS Enlargement of gingival tissues
Occurs as an exaggerated response to local irritation in boys and girls during puberty
S & S: affects mostly interdental papilla; swelling, redness, bleeding

22. GINGIVAL HYPERPLASIA
Use of anticonvulsant drug phenytoin (Dilantin) lead to chronic enlargement (hyperplasia) of gingiva
S & S: a) firm, pale pink resilient enlargement of gingival margin and interdental tissues b) no bleeding unless aggravated by secondary inflamation c) large portion of crown covered by tissue overgrowth

23. GINGIVAL INDEX (GI) Developed in 1960’s by Loe & Silness
Index most frequently used to evaluate gingivitis
Bleeding is most critical factor
Assess bleeding, colour, contour, and ulceration of tissue
Grades gingiva on M, D, B, L surfaces
Use on all or 6 selected teeth
GI Index = Total score # surfaces
Excellent = 0
Good = 0.1 – 1.0
Fair =
Poor = 2.1 – 3.0

24. GINGIVAL BLEEDING INDEX
Assess bleeding of gingival margin in response to gentle probing
Used as an indicator of gingival health or disease
# bleeding areas gingival margins examined x 100
+ = bleeding within 10 seconds after gentle probing
- = absence of bleeding after 10 seconds after probing
A positive score indicates percentage of all gingival areas explored that bleed in response to probing

25. 5. NECROTIZING ULCERATIVE
PERIODONTITIS
1. ADULT
2. PREPUBERTAL
3. JUVENILE
4. RAPIDLY PROGRESSIVE
5. NECROTIZING ULCERATIVE
6. REFRACTORY
7. PERI-IMPLANTITIS

26. ADULT PERIODONTITIS
Inflammation and infection that causes destruction of supporting tissues of tooth, including loss of connective tissue attachment to root surface; loss of periodontal ligament fibers and loss of alveolar bone
Overtime, continued periodontal destruction is associated with deep pockets, recession, furcations, mobility
Severity of condition increases with age
Site-specific ie: onset of disease can occur in some areas of mouth without affecting others

28. PREPUBERTAL PERIODONTITIS
Onset between eruption of primary dentition and puberty
Affects primary and mixed dentition
Localized - affects one or more primary molars that have lost alveolar bone
Generalized - widespread destruction of alveolar bone and early loss of primary teeth
S & S: a) severe gingival inflammation b) rapid bone loss c) tooth mobility d) tooth loss

29. JUVENILE PERIODONTITIS
Form of periodontal disease that occurs in adolescent
Localized - affects usually first permanent molars and incisors
Generalized - widespread destruction of alveolar bone; less acute signs of inflammation

30. RAPIDLY PROGRESSIVE PERIODONTITIS
Most of the teeth are affected
Extent of clinical signs of inflammation may be less than expected
age of onset years old

31. NECROTIZING ULCERATIVE PERIODONTITIS
Severe and rapidly progressive disease
S & S:
a) erythema of free and attached gingiva and alveolar mucosa
b) soft tissue necrosis
c) severe loss periodontal attachment
d) deep pocket formation usually not evident

32. REFRACTORY PERIODONTITIS
Destructive periodontal disease in clients who demonstrate attachment loss at one or more sites, despite therapeutic treatment and client’s efforts to stop progression of disease

33. PERI-IMPLANTITIS
A periodontitis-like process that can affect dental implants

34. PERIODONTAL INDEX (PI)
Developed by Russell in 1956
Assesses progressive stages of periodontal disease and amount of attachment loss present on each tooth
Easy to use and comprehend
Primarily used for major population groups
Attachment loss = sum of clinical probe depth and gingival recession
Recession - measured from CEJ to gingival margin
Tissues examined for gingival inflammation, pocket formation and masticatory function and given a score

35. PERIODONTAL DISEASE INDEX (PDI)
Evaluates gingival health, probing depths and plaque and calculus deposits
Used for ramfjord teeth: 16; 21; 24; 36; 41; 44
Gingiva given a score 0 – 3
Pockets given a score 4-6
Critical measurement is distance from CEJ to base of sulcus

36. PDI SCORING 0 = Absence of inflammatory signs
1 = Mild-to-moderate inflammatory gingival change that does not extend around the tooth
2 = Mild-to-moderately severe gingivitis that extends around the tooth
3 = Severe gingivitis characterized by marked redness, swelling and the tendency to bleed and ulcerate
4 = Gingival crevice extends apically past the CEJ but no more than 3 mm
5 = Gingival crevice extends apically 3 to 6 mm from the CEJ
6 = Gingival crevice extends apically more than 6 mm from the CEJ

37. 1st - measure the gingival crest to base of pocket to record pocket depth
2nd - CEJ is located by touch and depth from CEJ to gingival crest is recorded
Difference between the 2 gives indirect measure of LPA
Not ideal since LPA records the scars of past disease rather than present disease activity

38. EXTENT & SEVERITY INDEX (ESI)
Records the percentage of sites with the loss of periodontal attachment (LPA) greater than 1 mm and mean LPA for those affected sites
Method of summarizing data rather than a true index

39. CPITN – COMMUNTY PERIO INDEX
AKA: PERIODONTAL SCREENING & RECORDING (PSR)
Developed by WHO and FDI to assess treatment needs of specific groups
Approved by CDA and CAP
Not intended to replace a complete periodontal examination
Acts as a screening system to indicate when a full-mouth comprehensive examination is required

40. CPITN
Easy to use effective method to screen clients for periodontal disease and summarize necessary information with minimum documentation
Evaluates pockets, bleeding and plaque retention factors
Evaluates 6 sextants - 1 score from each sextant is used
Excludes 8’s unless they function as 7’s

41. CPITN
Requires own periodontal probe (CPITN-E probe) which has 0.5mm diameter ball at its tip, colour coded for visibility between mm and circular markings at mm
Purpose of ball - to assist in detection of overhanging margins and subgingival calculus and to facilitate assessment of base of pocket which reduces risk of overmeasurement

42. SCORING OF PSR
6’s and 7’s in posterior sextants are examined and only the deepest probing depth of each sextant is recorded
1 max ant tooth and 1 mand ant tooth are also examined ie: 1’s
Sextant with no teeth or 1 tooth is recorded as missing and marked “X” on record form
TN 0 = NO TREATMENT REQUIRED
TN 1 = REQUIRES IMPROVED OSC
TN 2 = REQUIRES IMPROVED OSC & DEBRIDEMENT
TN 3 = REQUIRES IMPROVED OSC, DEBRIDEMENT & COMPLEX TX

43. SCORING PSR
CODE 0
CODE 1
CODE 2
CODE 3
CODE 4

44. SIMPLIFIED ORAL HYGIENE INDEX (OHI-S)
Developed in 1960 by Greene and Vermillion; was modified 4 years later
Useful for large populations
Scores plaque and calculus together (both supra and subgingival)
Silness and Loe developed a Plaque Index (PI) designed to be used along with GI

45. PLAQUE INDEX (PI) Developed in 1967 by Silness and Loe
Assess thickness of plaque on teeth at the gingival margin
Specific teeth or entire dentition can be assessed using D, M, F, L surfaces
Visually examine plaque or use a probe to swipe along cervical third of teeth; disclosing agent can be used
The main difference between PI and OHI-S approach is that PI scores plaque according to its thickness at gingival margin rather than its coronal extent
0 - 3 ordinal scale is used

46. CONCLUSION OF STUDY CONDUCTED ON PRESCHOOL CHILDREN
It is necessary to find which method of oral hygiene instruction is more adequate for each child considering age
The results showed that the most effective method of oral hygiene instruction and reinforcement was individual instruction independent of the age of the child
This information is useful because this method is both inexpensive and easily taught.

47. SPECIFIC PLAQUE INDICES
Monitors OH performance
Indicates location of plaque
Assists in visualization of client’s home care progress
Assists clinicians in emphasizing specific areas of need and tailoring home care with alternative plaque control aides
# plaque surfaces present # tooth surfaces examined x 100 = P