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Amal's lecture

Periodontal Charting
Furcation Involvement:
MULTI-ROOTED TEETH: Lower molar 2 roots (one mesial & one distal) Upper first premolar 2 roots (one buccal & one facial) Upper molar (one MB, one DB, one palatal) probe from facial aspect between MB & DB + detect through & through from M & D between (MB & P + DB & P) When the inflammation extend to include the furcation area, called FURCATION INVOLVEMENT.. Examination: Clinically: using nabers probe in suspected deep periodontal pocket. Radiographically: X-ray with the probe in the pocket

Classification of furcation involvement:

Grade I & II are similar _ III & IV are similar Grade I: There is early bone loss or incipient loss. Suprabony pockets. Slight bone loss in the furcation detected clinically by slight catch. Radiographs are not useful since there is part of the inter-radicular bone intact hiding the bone destruction radiolucency. Clinical detection is more important than radiographical detection for this grade. Grade II: Bone is destroyed in one or more aspect of the furcation but portion of the interadicular bone & PDL remain intact. Partial entrance of the probe. They may be vertical bone loss. Radiographs may or may be not reveal grade II Grade III: The interradicular bone is completely absent. The furcation opening is through & through. Facial & lingual orifices are occluded by gingival tissue, so furcation opening can't be seen clinically. Radiographic Rl area between roots. Grade IV: The interradicular bone loss is completely destroyed. Gingival tissue is receded apically, so the furcation opening is clinically visible. Radiograph is similar to grade III

Furcation in horizontal direction:

Degree I (Initial): Horizontal loss of periodontal support not exceed to 1/3 of the width of the tooth.. (1/3 probe is inserted) Degree II (Partial): Horizontal loss of periodontal support exceeding 1/3 of the width of the tooth, but not the total width of the furcation area. (2/3 probe is inserted) Degree III (Total): Through & through ( the whole probe can pass through)

Mucogingival Problems:
Width of attached gingiva depth = (from Free gingival margin to mucogingival line) pocket depth. Attached gingival width differs from : 1. Site to site 2. Person to anther 3. Time to time The distance from the gingival margin to the mucogingival line is called KERATINIZED GINGIVA Mucogingival problem means: Insufficient amount of attached gingiva or high frenum attachment or the depth of the pocket extends beyond the mucogingival line or gingival recession extend to or beyond mucogingival junction.

Reduce or absent of attached gingival may be due to several factors:

1. The base of the periodontal pocket being apical or close to the mucogingival line. (insufficient amount of attached gingiva N.B: amount of attached gingiva < 10 mm insufficient 2. Frenal & muscle attachment that encroach on periodontal pocket & pull them away from the tooth surface. 3. Recession causing denudation of root surfaces & creating a function & aesthetic problems.

Methods for examination of mucogingival problem:

1. Tension test. (Objectives) : 1- Test done to detect the adequacy of the width of attached gingiva. The free gingival margin is stretched away from the tooth causing blanching in case of insufficient amount of attached gingiva on stretching forward the lips. 2- To locate frenal attachment & their proximity to the free gingival. 3- For identification of the mucogingival junction.

2. Observe relationship of gingival margin & mucogingival junction. Only inspection without measuring. 3. Observe color. (The gingiva is pale pink while the alveolar mucosa is red). 4. Probe(measurement) 5. Rolling test the gingiva is rolled occlusally using probe. (+ve movement coronally insufficient & -ve no movement coronally ) N.B: Gingival recession is indicative of loss of attachment & may lead to mucogingival problem but not indicative of periodontal pocket presence.

 Color observation is aided by swapping the gingiva with I2 ( Iodine stain) stain where alveolar mucosa can absorb the stain while the attached gingiva is keratinized resisting stain absorption & appearing pale

Examination of the mucogingival problems:

What's record? 1. Area where there is no attached gingiva 2. One mm or less 3. 2 mm or less when chch. by sings of inflammation

When the width of attached gingival 2mm or less & is associated with:
Teeth which may subjected to stressful restoration prosthesis or orthodontic treatment (used as abutment) Significant mobility, fremetus or other possible effect of traumatic occlusion (wearing fascetes) Base of the pocket relating to the furcation involvement. The area should be recorded & reviewed at the each phase I therapy.

Dental plaque:
Don't use the disclosing agent until the instructor has checked the gingiva. Thin plaque by explorer. Thick plaque by direct observation. Degrees: Localized, generalized _ slight, moderate, thick.

Calculus:
Supra calculus:
1. 2. 3. Observation (for very thin layers) location ( we should specify it) Amount, slight, moderate, heavy.

Sub calculus:
1. Observation (not seen clinically but their may be palling of gingival margin grayish color) 2. tactile examination 3. Location ( we should specify it) 4. Amount

Dental stain:
Color, source, distribution, localized, generalized, cervical 1/3 or surface Reevaluation after plaque control & scaling Polishing is a selective procedure (for appearance only)

Recording dental deposits:

1. removal of dental deposits: soft deposits removal during phase control Calculus removal during instrumentation in phase I Extrinsic stains with plaque & calculus 2. The number of appointments required for phase I: The extent of instruction necessary to patient for plaque control Amount & distance of calculus in conjunction with periodontal pocket.

Mobility:
Normal scale
N= Normal physiologic 1= Slight mobility (more than 1 mm) 2= Moderate (more than 2mm) 3= severe may move in all direction include the vertical.

Freimitus:
Freimitus is palpable vibration or movement Important sign during examination of the occlusion Commonly used as indicator of the need for further aalysis Fremitus may be detected in Vertical_ Protrusive_ Lateral

Fremitus Examination: In vertical Direction:

1. Patient in upright position during rest. 2. Ask the patient to click the posterior teeth. 3. Index finger of the dentist is inserted so that half of it covering the gingiva & the other half covering the cervical marginal third test of the upper third molar & the remaining holding the adjacent teeth for comparison. 4. Ask the patient to click. 5. Repeated on all teeth. 6. Record by tooth number where vibration is felt & where there is actual movement.

In protrusive Direction:
1. Patient in upright position. 2. Ask the patient to protrude the mandible till the anterior are edge to edge. 3. Then ask the patient to grid the teeth backward & forward. 4. Detect the fremitus using the index finger placed in the upper anterior teeth.

In lateral Direction:

1. Patient in upright position. 2. Ask the patient to move the mandible laterally till the teeth come in contact, then slide the teeth backward & forward 3. using index finger placed on the upper posterior teeth on both side separately. N.B: All examination is performed by index finger on the upper teeth only.

Nominal scale:
N Normal + Vibration felt 1 slight movement felt against finger 2 Clearly palpable, movement visible 3 Movement very apparent

Importance of O'Leary index:

as the index increase poor oral hygiene Compare between visits to evaluate plaque control measurement & patient attitude. Indication of the oral hygiene

Radiographic examination:
1. 2. 3. 4. Bone loss (horizontal or angular) Furcation involvement Lamia dura crestal r overall) PDL space

Bone loss:
A) B) horizontal generalized, localized mild: bone loss than 1/3 of the root Moderate : bone loss more than 1/3 & less than 1/2 of the root Severe: bone loss more than 1/2 of the root. Angular specify by location

N.B: If there is bone loss periodontal problem _ periodontitis but never gingivitis. Early sign of destruction doesn't appear in the radiographs Radio doesn't give a true amount of destruction (less than clinically) Clinical detection is much more important than radiographically for bone loss detection the difference between alveolar crest height & radiographic appearance. Study revels that (0-1.6 mm) average range of the different between radiographic & clinical examination) Horizontal can be generalized or Localized, but Angular only localized. ARC Angular + Furcation involvement FUNELLING early sign of trauma of occlusion of PDL space. Localized Juvenile periodontitis chch. by mirror image of bone loss, and localization (maxillary anteriors & 1st molars).

Furcation involvement:
Radiolucent between roots a) Write tooth # b) Place a black dot on the dental charting

Lamina dura:
a) Crestal: Fuzzy, irregular, indistinct missing b) Overall: Thickened (thick white area) PDL space (periodontal ligament) widened (black line around funneling)

Others:
a) b) c) d) e) Over hanging restoration Root resortion Variation in root form, crown/root ratio Bone density: size of trabecular spaces Pulp stones

f)

Atypical Rl or Rp which may be significant for PD health.

Overhanging filling:
By explorer tip around all margins to detect irregularities Radiograph reveal only proximal overhangings & when there is no superimposition or overlap of teeth Black triangle tooth diagram

Charting Key:
Missing tooth Unerupted tooth Impacted tooth Tooth to be extracted Drift & path migration P Encircle tooth Encircle tooth

M Gingival margin Mucogingival Junction Overhang Food Impaction Open contact Furcation involvement caries Existing restorations Defective Temporary Crown Bridge Periapical Lesion Endo

Probe depth(mm) red circle around Probing depth is better term than pocket depth because probing means: Normal sulcus depth or pocket but pocket is specific for pathologic epithelial migration. Mobility (N-1-2-3) Black Line Green line ( at occlusal) ( at the occlusal) ( at occlusal) ( in furcation) red Blue/black Circle in red Circled in red with T Outline occlusal = Circle apex Draw in