Periodontal Diagnosis
Six months ago, when I sat down to write my bi-monthly dental-themed article I decided to take a new patient's dental experience and really get into the nuts and bolts of everything your Dentist and Dental Hygienist do in that initial visit. The first type of data gathering we do is capturing dental x-rays so, six months ago, I decided to write about dental x-rays. A few paragraphs into that first article and I realized I was going to need more than 2 pages in a magazine to be as thorough as I thought warranted. It turned out I needed 6 pages and that initial topic turned into a 3-part dental x-ray saga. I gave the reader a very good education on the why, how, what, and when of dental x-rays and why they are so important to my profession.
So now the new dental patient, still in the hygiene chair, has just completed having the necessary x-rays taken and the Hygienist will move on to the next part of the Comprehensive New Patient Examination...the Periodontal Diagnosis. Periodontics is the branch of dentistry concerned with the structures surrounding and supporting the teeth, and for the lay person the structures supporting our teeth are the jaw bones and our gingiva (aka gums).
A thorough periodontal diagnosis is obtained objectively by reviewing the freshly taken x-rays, by looking directly for signs of plaque build-up and/or inflammation, and by probing around the teeth to measure the gingival pocket depths.
1. What can Dental X-rays inform us about a patient's periodontal condition?
Since you are all x-ray experts after my last 3 articles, I will tell you that posterior bitewings and anterior periapical x-rays can give us a pretty good assessment of bone level, and whether or not there is any hardened plaque/tarter hiding underneath the gum tissue. We refer to this calci- fied plaque as Calculus. The bitewing provided is a great example of this condition with the obvi- ous calculus "spur" attached to the bottom tooth.
2. What can we learn from a direct visual exam about a patient's periodontal condition?
The three conditions we would rather not see are red, puffy gums that bleed easily (aka gingival inflammation or gingivitis), the presence of visible plaque build-up, and gum recession which indicates loss of bone. Or any combination of the three.
3. What the heck is periodontal probing?
Everyone who sees their Dental Hygienist regularly should be familiar with this process. As the image portrays, a periodontal probe is a thin blunted instrument with demarcation lines indicating one millimeter. A proper probing will result in 6 measurements per tooth and should not be uncomfortable.
The hygienist is measuring pocket depth and also the amount of gum recession present if any. The combination of these two measurements gives us a "Clinical Attachment Loss" value. In other words, it tells us if any bone loss has occurred.
Let's further define a few terms. Periodontitis is a gum and bone disease defined by the loss of bone around teeth. This bone loss for all intents and purposes is non reversible without surgical intervention but can be arrested and maintained. Gingival inflammation will be greatly reduced if maintained properly, but will be present if not maintained sufficiently. Leading to more bone loss. Now, gingival inflammation without the presence of bone loss is called Gingivitis and is wholly reversible. Untreated gingivitis results in periodontitis. Phew.
Okay, so the hygienist has gathered all the data needed to make a detailed diagnosis for this new patient. It will fall into one of four classifications: 1. Healthy 2. Mild 3. Moderate 4. Severe. And will either be localized or generalized or a combination of the two. Here are some examples of how a dentist might document a patient's periodontal condition:
1. Patient has generalized health with localized mild periodonti- tis in the upper right posterior.
2. Patient has generalized moderate to severe periodontitis with generalized mobility.
Finally, once we have a diagnosis, we can prescribe the type of dental cleaning that the patient requires to restore or maintain healthy gums. and bone. There are really 4 types of cleaning in the United States dental codes.
1. The adult or child prophylaxis, or "Prophy"
a. This cleaning is for those with mostly healthy gums with very little to no calcified plaque build-up above or below the gums. If you have good home dental hygiene then you will likely fall into this camp.
2. The Gross Debridement
a. This one is probably the rarest, and it occurs when there is so much plaque and tarter that it is not possible for the hygienist to probe or for the dentist to do an evaluation of the dentition.
3. The Scaling & Root Planing
a. Recommended when there is typically 2 or more millimeters of bone loss resulting in deeper pockets of 5mm or greater with the presence of Calculus. These cleanings are recommended by quadrant and designated as limited (1 to 3 teeth) or full (4 or more teeth). The lay person might have heard this referred to as a "deep cleaning," but I like to call it a "more advanced cleaning." This cleaning is done to eliminate the source of inflammation and stop further loss of bone.
4. The Periodontal Maintenance
a. This cleaning is for patients who have completed a "more advanced cleaning" and are maintaining their bone levels. These patients still have deeper pockets but the sub-gingival calculus has been removed and tissues are advancing towards health. These maintenance cleanings can be prescribed 2, 3, or 4 times annually depending on need.
Wow, hopefully we didn't get too into the weeds on this one. Bottom line is the human body uses inflammation to fight off pathology. In the case of gum disease, the source of the inflammation is the presence of plaque in all its forms. Unlike cuts and scraps which the body can heal, the body cannot remove calcified plaque on its own and so its response is retreat from it causing bone recession. Please see your friendly neighborhood dental hygienist regularly, and if your teeth and gums are healthy, you'll be in and out quicker and the bill will be cheaper.
Happy Spring Montana. Keep Smiling!
Read Periodontal Diagnosis by Dr. John F. Miller, DDS, in 406 Woman magazine.