JADA A R T I C L E S
Diagnosis is a critical step in evaluating the patient's periodontal health and aids in satisfy ing dentolegal requirements in monitoring and recordkeeping.
Diagnosing periodontal diseases Erwin P. Barrington, DDS, PhD; Myron Nevins,DDS
h e diagnosis o f p e rio d o n ta l disease re q u ire s a clinical ev aluation o f th e p a ti e n t in c lu d in g visual fin d in g s, th e u se o f th e p e r i o d o n ta l p r o b e , a n d rad io g ra p h s. N o te st is available to evalu a te d is e a s e a c tiv ity . In s p e c if ic c a s e s , ad junctive p ro c e d u re s m ay also be useful. T h e id en tificatio n o f p a th o g e n ic m icro o r g a n is m s m ay a id in e v a lu a tin g th e p e r i o d o n ta l s ta tu s o f s p e c ia l p a tie n ts . D iagnosis is a critical step in evaluating th e p a ti e n t’s p e r io d o n ta l h e a lth a n d aid s in satisfying d en to le g a l re q u ire m e n ts in m o n ito rin g a n d re c o rd k e e p in g . P e r i o d o n ta l d is e a s e s a r e th e le a d in g cause o f to o th loss in ad u lts '■» a n d are well re c o g n iz e d by th e d e n ta l p ro fessio n a n d , increasingly by th e public, as a significant h e a lth p r o b le m . F o rtu n a te ly , w ith e arly d e te c tio n a n d tre a tm e n t, it is possible fo r m ost p e o p le to re ta in th e ir te e th fo r a life tim e .4-6 T o a c h ie v e th is g o a l, ev ery o ra l ex a m in a tio n sh o u ld in c lu d e a n evaluation o f th e p e rio d o n tiu m . A sim p le p e rio d o n ta l sc re e n in g ex a m i n a t i o n c a n d e t e c t p e r i o d o n t a l d is e a s e easily in a m in im u m o f tim e. T his ex am i n a tio n s h o u ld b e sensitive to n o te devia tions fro m h e a lth a n d in c lu d e all sites. It is a c ritical ste p in ev a lu a tin g th e p a tie n t’s p e r io d o n ta l sta tu s a n d a id s in satisfying d e n to le g a l r e q u i r e m e n ts in m o n ito r in g an d re c o rd k e e p in g . It is a x io m a tic to say th a t d ise ase is a v ariatio n fro m h e a lth , yet th e c o n c e p t o f p e r io d o n ta l h e a lth m u s t b e u n d e rs to o d b efo re we can d iag n o se disease. P e rio d o n tal h e a lth m ay b e d e sc rib e d as 7:
T
T h e p e rio d o n tiu m is com p o sed of gingiva, perio d o n tal ligam ent, cem entum , and alveolar b one. T h e gingiva e x te n d s fro m the gingival m argin to the m ucogingival ju n ctio n (except on the palate) and this width becom es greater with age. In health, the color o f the gingiva is uni form a n d pale pink, b u t variation occurs as the result o f d e g re e o f keratin izatio n , p igm enta 4 60 ■ JA DA , Vol. 121, O c to b e r 1990
tion, thickness, a n d vascularity. T h e m arginal gingiva is scalloped a n d becom es th in n er coronally to m e e t th e to o th su rface w ith a knife edge m argin. Gingiva fills the interdental space w hen a d ja c e n t te e th a re in c o n ta ct, a n d this interdental gingiva consists of ora! and vestibu lar peaks co n n ec te d b e n e a th the c o n ta ct area by the col. H ealthy gingival tissue is firm and nonm obile. T he surface texture may be sm ooth or stippled. T h e gingival sulcus can be probed to approxim ately 1 m m or m ore in depth. T he p o sitio n o f th e gingival m arg in a n d gingival contour and thickness dep en d to a great extent on the position o f the associated teeth.
H e a l t h y p e r i o d o n t a l tis s u e is n o t in fla m e d .8 T h e physical c h a ra c teristics o f th e tissu e sh o w a p p r o p r ia te c o lo r, size, sh a p e, co n sisten cy , c o n to u r, a n d te x tu re . H e a l t h y ti s s u e d o e s n o t b l e e d w h e n p ro b e d gently, has n o crevicular fluid flow, a n d p ro b in g d e p th s are 1 to 3 m m . R adio g ra p h s o f b o n e tissu e show in ta c t crestal lam in a d u ra th ro u g h o u t th e d e n titio n a n d in ta c t in ter-ra d ic u la r b o n e . W hile th e severity o f p e rio d o n ta l disease m ay v ary , it is lik e ly t h a t it a ff e c ts th e m ajo rity (u p to 8 0 % ) o f th e US p o p u la tio n .1 T h e basic p a th o lo g ic al p rocesses in th e p e rio d o n ta l diseases are in flam m atio n a n d re la te d im m u n o p a th o lo g ic a l variatio n s.912 T h e p rim a ry cause o f p e rio d o n ta l disease is b a c te ria l p la q u e .13-^ T h u s , th e disease m a n ife sta tio n is th e classic h o st-b a c te ria l in t e r a c t i o n 1116. ^ w ith th e c lin ic a l sig n s b ein g th o se involved in th e in flam m ato ry process. C o n te m p o ra ry p e rio d o n tic s reco g n iz e s several fo rm s o f p e rio d o n titis , in c lu d in g som e th a t afflict c h ild re n a n d adolescents. T h o se f o u n d in th e e a rly ag e g ro u p s , as well as ad u lts, m ay a c co m p an y a systemic d is o rd e r. A lth o u g h th is a rtic le c o n c e n tr a te s its a tt e n ti o n o n th e d ia g n o s is o f c h r o n ic a d u lt p e r i o d o n ti ti s , we r e c o m m e n d a p e r io d o n ta l e x a m in a tio n fo r all y o u n g p a t i e n t s . T h e a c c e p t e d c la s s
ific a tio n 18 fo r c h ro n ic a d u lt p e rio d o n titis fro m th e A m erican A cadem y o f P eriodonto lo g y ’s C u r r e n t P ro c e d u ra l T erm in o lo g y (Fig 1-3) follows.
F ig 1 ■ H e a lth y gingiva a n d b o n e .
F ig 2 ■ T h e p r o g r e s s o f slig h t p e r io d o n ta l d is e a se .
F ig 3 ■ A d v a n c e d p e r i o d o n t a l d i s e a s e . E v e n th o u g h b o n e is d e s tro y e d , th e g in g iv al tiss u e m ay re m a in in p o s itio n a r o u n d th e te e th a n d r e p r e s e n ts th e c h a n g e s in b o th p r o b in g d e p th a n d a tta c h m e n t lo ss a s th e d is e a s e p ro g re s s e s .
A R T I C L E S ^
I. Gingivitis
III. M oderate periodontitis
In flam m atio n o f th e gingiva c h a racterized c lin ic a lly by c h a n g e s in c o lo r , g in g iv a l fo rm , p o s itio n , s u rfa c e a p p e a ra n c e , a n d p re se n c e o f b le e d in g a n d / o r e x u d ate .
A m o r e a d v a n c e d sta g e o f th e fo r g o in g c o n d itio n , w ith in c re a se d d e s tru c tio n o f th e p e rio d o n ta l stru c tu re s w ith n o ticeab le loss o f b o n e su p p o rt possibly a c c o m p an ie d by a n in c re a s e in to o th m o b ility . T h e re m ay b e f u r c a tio n in v o lv e m e n t in m u lti ro o te d tee th .
II. Slight periodontitis P ro g ressio n o f th e gingival in fla m m a tio n in to th e d e e p e r p e rio d o n ta l stru c tu re s a n d a lv eolar b o n e crest, w ith slight b o n e loss. T h e usual p e rio d o n ta l p ro b in g d e p th is 3 to 4 m m with slig h t b o n e loss o f c o n n e c tive tissu e a tta c h m e n t a n d slig h t loss o f alveolar b one.
IV. Advanced periodontitis F u rth e r p ro g re ssio n o f p e rio d o n titis w ith m a jo r loss o f alveolar b o n e su p p o rt usually a cc o m p a n ie d by in cre ase d to o th mobility. F u r c a t io n in v o lv e m e n t in m u l ti r o o t e d te e th is likely.
V . Refractory progressive periodontitis In c lu d es several unclassified types o f p eri o d o n ti ti s c h a r a c te r iz e d e i t h e r by ra p id b o n e a n d a tta c h m e n t loss, o r slow b u t co n tin u o u s b o n e a n d a tta c h m e n t loss. T h e re is re s ista n c e to n o rm a l th e ra p y , a n d th e c o n d itio n is usually asso ciated w ith gingi val in fla m m a tio n a n d c o n tin u e d p o c k e t fo rm atio n .
F ig 5 ■ P e r io d o n ta l p r o b in g d e p th s a n d a tta c h m e n t lo s s . T h e p e r i o d o n t a l p r o b e is i n s e r t e d
A p e r i o d o n t a l s c r e e n i n g e x a m i n a ti o n sh o u ld b e a fu n d a m e n ta l p a rt o f all d e n tal e x am in atio n s. W hen this su p erficial exam in a t io n re v e a ls p e r i o d o n t a l p o c k e ts o f g re a te r th a n 3 m m , b le e d in g o n p ro b in g , f u r c a tio n in v a s io n , m u c o g in g iv a l p r o b lem s, m obility, o r recession e x c e e d in g 3.5 m m , a c o m p reh en siv e evalu atio n m u st be m ad e. T h e f i r s t s t e p w h e n e x a m i n i n g th e p a tie n t is u sin g th e p ro p e r c o m p o n e n ts to establish a diagnosis. T h re e are n e e d e d : a visual e x a m in a tio n , p ro b in g e x a m in a tio n , a n d a rad io g ra p h ic e x a m in a tio n .19
a lo n g th e lo n g ax is o f th e to o th a n d m e a s u re s a 1 m m p o c k e t d e p th . N o te th a t a tta c h m e n t lo s s as
Evaluation o f clinical parameters
m e a s u r e d f r o m th e c e m e n to e n a m e l ju n c tio n to th e b a s e o f th e p o c k e t is 4 m m .
T h e f o u r c ritic a l a re a s a re th e p h y sic a l c h a r a c t e r i s ti c s o f t h e tis s u e s , p r o b i n g d e p th a n d a tta c h m e n t loss, b le e d in g with p ro b in g , an d th e results o f th e full-m outh ra d io g ra p h ic survey.
Physical characteristics of the tissues
F ig 6 ■ B le e d in g o n p r o b in g is o n e o f th e f o u r critic a l clin ical p a ra m e te rs .
g | I \ | | I | i I | j
I i I I j I
Patient examination
s w o lle n , sh in y, a n d g lis te n in g . B lo o d v e s s e ls a r e e n g o rg e d w ith e x u d a te fro m th e gingival m a rg in .
I j
Probing depth
F ig 4 ■ C h an g e s in th e p h y sical ch a ra c te ris tic s o f t h e ti s s u e o v e r t h e r i g h t c a n in e . T h e ti s s u e is
i n f l a m m a t o r y p r o c e s s m a y r e s u l t in sw elling a n d a c h a n g e in th e c o lo r o f th e ti s s u e s as p l a q u e a n d c a l c u l u s a ccu m u late. Tissues can b e co m e e n la rg e d a n d m o re fib ro tic w ith ro lle d m arg in s, a n d th e pyram id s h a p e d i n t e r d e n t a l p a p i l l a e c a n b ec o m e m o re fla tte n e d as p e rio d o n ta l disease progresses. T h e te x tu re o f th e gingiva m ay lose its stip p led c h a ra c te r a n d b eco m e sm o o th a n d g listen in g . As th e disease p ro gresses, th e gingiva b eco m e s m o re fibrotic a n d firm a n d is less g listen in g . T h e gingiva m ay even b e c o m e e n la rg e d , a n d iso lated areas o f recession may occur. T h e d im en sion o f k e ra tin iz e d a tta c h e d gingiva, with th e lo c a tio n o f th e fre e gingival m arg in , is im p o rta n t to observ e a n d re c o rd . P rogressive recessio n m ay w a rra n t co rrectiv e tre a t m e n t a n d m ay be a c o n s id e ra tio n fo r p a tie n ts w ho a re c a n d id a te s fo r o rth o d o n tic tr e a t m e n t o r m a jo r r e s to r a tiv e d e n tistry. T h e p h y sical c h a ra c te ris tic s o f th e tissu e s c h a n g e in r e la tio n to th e q u a n tity , q u a lity , d u r a t i o n , a n d in t e n s i ty o f th e in flam m ato ry process.
T h e e v a lu a tio n o f p e r i o d o n t a l tis s u e s d e p e n d s o n th e p h y sical c h a ra c te ristic s: c h a n g e s in color, size, sh ap e, consistency, te x tu re , a n d c o n to u r (Fig 4). A visual ex am in a tio n as well as p a lp atio n o f th e tissu es c a n id e n tify c h a n g e s. T h e
T h e p a th o g n o m o n ic fe a tu re o f a d u lt perio d o n titis is th e p e rio d o n ta l p o c k e t.7 T h e in flam m ato ry p ro cess can re su lt in p o c k e t f o r m a tio n , d a m a g in g th e ju n c t io n a l e p ith e liu m a n d th e s u lc u la r e p ith e liu m . S e p a ra tio n o f th e ju n c t io n a l e p ith e liu m a p p e a rs to c o in c id e w ith e p ith e lia l ap ical m i g r a t i o n , le a v in g a s p a c e f i ll e d w ith p la q u e , calc u lu s, a n d c e llu la r d e b ris.9-20-21 T h e s t a n d a r d by w h ic h th e p e r io d o n ta l p o c k e t is m e a s u r e d is th e p e r i o d o n t a l p r o b e . A n a r r o w , r o u n d p r o b e w ith b lu n te d p o in t a n d m ille m e te r ca lib ra tio n sh o u ld b e used. R e c o rd in g s u su ally in c lu d e th e m esial a n d distal in te rp ro x im a l a n d facial o r ling u al a sp e c t o f e a c h to o th . It is im p o rta n t to p ro b e directly u n d e r th e c o n ta c t p o in t, m a in ta in in g th e p ro b e p arallel to th e lo n g axis o f th e to o th (Fig 5 ). S uch re c o rd in g s allow a site-specific a n d g e n e ra liz e d evaluatio n o f th e p a tie n t-7-21-24 T h e use o f th e p e rio d o n ta l p ro b e elucid ates th e physical ch aracteristics as well as th e d e p th o f th e p o c k e t. P r e s e n c e o f a p o c k e t d e p ic ts p a st d e s tru c tio n a n d d o es n o t d e te rm in e th e c u r r e n t activity o f th e disease p ro cess.7-19-22-2527 In g e n e ra l, a perio d o n ta l p ro b in g d e p th is m e a s u re d from th e g in g iv a l m a r g in to th e b a s e o f th e p o c k e t w ith 1 to 3 m m c o n sid e re d w ithin th e ra n g e o f h e a lth . H o w ev er, b le e d in g a n d flu id e x u d a te w ith p r o b in g in d ic a te JADA, Vol. 121, O cto b er 1990 ■ 461
J j
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J I I
j j j 1 I f
j j j j
s I f 1
I j * I
A R T I C L E S
p a th o s is , re g a r d le s s o f th e p ro b in g d e p th .7-28-30 T h e d e p th re c o rd e d m ay n o t accurately r e f l e c t t h e h i s t o l o g i c a l d e p t h o f th e p o c k e t, b e c a u s e th e p r o b in g fo rc e a n d a n g u la tio n , c o u p le d w ith p a tie n t sensitivity levels a lt e r th e r e a d in g s .7-25-31-35 B a se lin e p ro b in g d a ta sh o u ld b e c o lle c te d b e fo re a n d a fte r in itial d e b rid e m e n t th erap y , to m e a s u re th e im p ro v e m e n t a tta in e d w ith n o n su rg ic a l p ro c e d u re s. B o th u n d e r- a n d o ver-probing can o c c u r a n d a lte r th e p e r ce p tio n o f th e tru e severity o f th e disease. A tta c h m e n t loss is a relative n ew co m er to p e r io d o n ta l m e a s u re m e n ts . 19.22.2» T h is m e a s u re m e n t— ta k e n fro m a fix ed p o in t, u su ally th e c e m e n to e n a m e l ju n c t io n , to th e b a s e o f th e p o c k e t— in d ic a te s h o w m u c h a c tu a l loss o f p e r io d o n ta l a tta c h m e n t h a s o c c u r r e d . T h is m e a s u r e m e n t in d ic a te s th e e x te n t o f p r io r d e stru c tio n , n o t disease pro g ressio n . It is c o n sid e re d a m o r e a c c u r a t e b a s e l in e o f th e d is e a s e state. T h ese m e a su re m e n ts a re invaluable in c lin ic a l r e s e a r c h , b e c a u s e th e y u s e d fixed re fe re n c e p o in ts fo r fu tu re c o m p a r isons. Bleeding upon probing T h e p ro b in g ex am in atio n may elicit b le e d in g w ith o n ly a g e n t l e p r o b i n g f o r c e , w hich in d icates in flam m a tio n b u t is a lim ite d p re d ic to r o f p e rio d o n ta l disease activ ity (Fig 6 ).36-37 It is p o ssib le to have d e e p p o c k e t d e p th in th e ab se n c e o f b leed in g , b u t it d o es n o t in d ic a te th e ab sen ce o f dis ease. B leeding can be m o d ifie d by systemic m e d ic a tio n , in c lu d in g a n tib io tic s , w h ich f u r th e r affe c ts its d ia g n o s tic lim ita tio n s. T h e a c c e p te d fo rce to evaluate fo r b le e d in g p o in ts is a p p ro x im a te ly 20 to 25 lb , ap p ro x im ately th e fo rce u sed to in se rt th e p e r io d o n ta l p ro b e u n d e r th e fin g e rn a il bed.
te e th . A p a n o r a m ic r a d i o g r a p h c a n be u s e d as a s u p p le m e n ta l d ia g n o s tic to o l, b u t is n o t a d e q u a te fo r p e rio d o n ta l d iag no sis. 7-24 T h e d a ta o f th e se in v estig a tio n s sh o u ld b e c o rre la te d to re a c h a m e a n in g ful d iagnosis a n d to p lan a p p ro p ria te tre a t m e n t.
Diagnosing disease breakdown Is it possible to d iag n o se th e state o f active p e rio d o n ta l breakdow n? T h is q u e stio n has b e e n th e su b ject o f intensive re se a rc h fo r m any years a n d th e re are in d ica tio n s th at t h i s e lu s iv e c o n c e p t m a y y e t b e a c h ie v e d .722,4° Ideally , a to tally o b jec tiv e d ia g n o s tic te s t w o u ld b e a g r e a t a s s e t, a lth o u g h n o such test cu rre n tly exists. T h e q u e s tio n s o f how o fte n , h o w ra p id , a n d how lo n g th e active lesio n is in p ro g re ss a re n o t resolved a n d a re o p e n to investiga tio n . C onsequently, th e c u rr e n t ev aluation o f p e rio d o n ta l disease is b ased o n m an y diag nostic tools a n d clinical ju d g m e n ts as well as c lin ic a l e x p e r ie n c e s .7-24 N o n e th e le s s , a d d itio n a l d ia g n o s tic a id s a re a v a ila b le a n d c a n be view ed as a d ju n c tiv e tests at this tim e. Adjunctive tests
Radiographic techniques In a d d itio n to th e p h y sic a l c h a r a c te r is tics— p ro b in g d e p th s , a tta c h m e n t loss, a n d b le e d in g o n p ro b in g , a n o th e r im p o rta n t diagnostic aid is th e ra d io g ra p h (Fig 7). A n in itial fu ll-m o u th series o f in tra o ra l ra d io g ra p h film s, in c lu d in g bitew ings a re n e e d e d to e v a lu a te t h e o s s e o u s tissu es. 24.s8.39 T h e p a ra lle lin g te c h n iq u e can p r o d u c e a m e a n in g f u l i n t r a o r a l r a d i o g ra p h . T h e tw o-dim ensional ra d io g rap h is a re d u c tio n o f a th re e -d im e n sio n a l to o th a n d alveolar process a n d illustrates th e loss o f in tra p ro x im a l a n d in te rra d ic u la r b o n e , b u t may be m islead in g in d e te rm in in g th e loss o f b o n e o n th e ra d ic u la r su rfa c e o f 46 2 ■ JADA, Vol. 121, O ctob er 1990
A d d itio n al testing m e th o d s a re available to h e lp establish th e diagnosis o f p e rio d o n ta l diseases. T h e re c o g n itio n o f p e rio d o n ta l diseases as infectio u s has fo cu sed research in th e id e n tificatio n o f specific p ath o g en s. F o r years, p e rio d o n ta l disease was c o n sid e r e d r e l a t e d to th e m a s s o f b a c t e r i a l p la q u e o v e rw h e lm in g th e h o s t d e fe n s e m ech a n ism .4' T h is c o n c e p t o f n onspecific p la q u e h as re c e n tly b e e n c h a lle n g e d by r e s e a r c h id e n t i f y i n g s p e c i f ic s p e c ie s re la te d to th e d isease.42 T h ese species iso la te d a re m ostly g ra m -n e g a tiv e a n e ro b ic ro d s a n d in c lu d e Bacteroides g in g iv a lis, Intermedius, Actinobacillus actinomycetemcomitans a n d o th e rs.43-45
Culturing. O rg an ism s may be c u ltu re d an d
isolated in a la b o ra to ry settin g a n d selec tive m e d ia can be used to h e lp identify var io u s s p e c i e s . 740 O n e s id e b e n e f i t o f c u ltu rin g te c h n iq u e s is th a t an tib io tic sen sitivity ca n be d e te r m in e d fo r th e a p p ro p riate an tib io tic if sign ifican t tre a tm e n t is w a rra n te d . B acterio lo g ic te stin g la b o ra to ries a re av ailable c o m m e rc ia lly a t several u n iv e rsitie s . U n fo rtu n a te ly , d is e a se p r o g ression c a n n o t be p re d ic te d o n th e basis o f id e n tific a tio n o f th e p u tativ e m ic ro o r ganism s. Darkfield and phase contrast microscopy.
T h e se te c h n iq u e s have b e e n u se d m ainly as c h a irsid e m e th o d s to id en tify b acterial m o rp h o ty p e s , a lth o u g h th e y have h a d a w eak c o rre la tio n with th e p re se n c e o f dis ease.47-48 It is d ifficult to relate th e fin d in g o f s p ir o c h e te m o b ility to c h r o n ic a d u lt p e r io d o n titis as g ra m -n e g a tiv e ro d s a re b elieved to b e th e etiologic agent. M icroscopic m o n ito rin g has b e e n used in c o n ju n c t io n w ith m a i n te n a n c e a fte r p e r i o d o n t a l t r e a t m e n t a n d h a s sh o w n slig h t c o r r e la tio n b e tw e e n sp e c ific m o r p h o ty p e s a n d th e p re s e n c e o f in fla m m a tio n . H o w ev er, m ic ro s c o p ic m o n ito r in g has n e v e r b e e n effective fo r th e evaluation o f p e rio d o n ta l disease activity o r as a p re d ic to r fo r disease activity. DNA probe. T his la b o ra to ry to o l identifies
sp e c ific s e q u e n c e s o f n u c le ic a cid s th a t c o m p r is e t h e D N A c h r o m o s o m e s a n d id en tifies individual m icro o rg anism s, with a h ig h d e g re e o f sp ecific ity a n d sensitiv ity.49-51 At this tim e, tests exist fo r ju s t th re e m i c r o o r g a n is m s , A c tin o b a c illu s actinomycetemcomitans, B gingivalis, a n d B inter medius, b u t ad d itio n al p ro b e s m ay so o n be available. In th is te c h n iq u e , a subgingival p la q u e sam ple is se n t to a c o m m erical lab o ra to ry fo r analysis. T h e test is sim p le to use in a d e n ta l office a n d results a re fairly a c c u ra te w h e n c o r r e la te d w ith c u ltu rin g
A R T I C L E S
te ch n iq u es. H ow ever, this te c h n iq u e sam ples fo r only th re e m icro o rg an ism s a n d as least six to eig h t have b e e n strongly im p li cated in p e rio d o n ta l disease activity. T his te c h n iq u e n e ith e r p red icts disease activity n o r allows sensitivity testin g o f antibiotics. Cervicular fluid assay. Tissue d estru c tio n is critical.7-2'228-40 C o n n ectiv e tissue a n d b o n e u n d e rg o d e s tr u c tio n in p e r io d o n ta l dis eases. As tissue is d estro y ed by th e in flam m a to ry a n d im m u n o lo g ic p ro c e sse s, th e d estru c tiv e activity o f th e disease c a n b e m o n ito re d by v arious enzym e analyzes o f d e g ra d a tio n p ro d u c ts fo u n d in th e g in g i val c e rv ic u la r flu id .7-52-53 M e a s u re m e n t o f c e rv ic u la r flu id flow o fte n in d ic a te s g in givitis, b u t does n o t c o rre la te as well with p erio d o n titis. Adjunctive periodontal probing. T h e fu tu re
T h e a u th o rs th a n k Dr. R o b e rt G. S c h a llh o rn fo r his advice a n d g u id a n c e in th e p r e p a r a tio n o f th is p a p e r a n d to M rs. M aria E q u ih u a fo r s e c re ta ria l assistan ce.
21. P a g e RC, S c h r o e d e r H . P a th o g e n e s is o f in fla m A m e ric a n D e n ta l A sso ciatio n a r e in v e stig atin g d e v e lo p m e n t o f a P e rio d o n ta l S c r e e n in g E x a m in a tio n w h ich
w o rk . L a b In v est 1976;4:235. 22. H a ffa je e AD, S o cran sk y SS, G o o d so n JM . C lin i
will p ro v id e d e n tis ts w ith an effectiv e a n d ra p id m e an s
cal p a r a m e te r s as p r e d ic to r s o f d e s tru c tiv e p e r io d o n ta l d isea se activity. J C lin P e r io d o n to l 1983;10:257.
to d e t e c t p e r i o d o n ta l d is e a s e s . A ll m e m b e r s o f th e d e n ta l p ro fessio n will b e g iven full in fo rm a tio n o n this e x a m in a tio n w h e n d e v e lo p m e n t is c o m p le te . D r. B a rrin g to n is in p riv a te p ra c tic e a n d p ro fe s s o r o f P e rio d o n tic s , U niversity o f Illin o is a t C h ic ag o , d e p a rt m e n t o f p e r io d o n tic s , B o x 6 9 9 8 , C h ic a g o , IL 60680.
C lin P e r io d o n to l 1984; 11:21. 24. G u id e lin e s fo r p e r io d o n ta l th e ra p y . In : A m e ri ca n A cad em y o f P e rio d o n to lo g y , ed s. C u r r e n t
P ro c e
D r. N evins is also in p riv ate p ra c tic e a n d is th e co-direct o r o f th e I n s tit u te f o r A d v a n c e d D e n ta l S tu d ie s in S w am pscott, MA. S e n d re q u e s ts fo r re p rin ts to Dr. B ar
it m e a n ? J C lin P e rio d o n to l 1980;7:165.
rin g to n .
26. G r e e n s te in G. T h e s ig n ifican ce o f p a c k e t d e p th m e a s u r e m e n ts . C o m p e n d C o n tin E d u c D e n t 1984;5:49. 27. C a to n J G , G re e n s te in G , P o is o n AM. D e p th o f
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p e rio d o n tic s .
S t.
L o u is :
L o e H . E p id e m io lo g y o f p e r i o d o n ta l d is e a se .
Adjunctive radiography. In a d d itio n to trad i
------------------- J!*OA------------------
23. S o cran sk y SS, H affaje e A D, G o o d so n JM , L in d h e J . N ew c o n c e p ts o f d e s tru c tiv e p e r io d o n ta l d is e a se . J
d u r a l T e rm in o lo g y . 5 th e d . C h ic a g o : T h e A m e r ic a n A cad em y o f P e rio d o n to lo g y ; 1988. 25. L istg a rte n MA. P e rio d o n ta l p ro b in g : W h a t d o e s
o d o n to l 1982;53:539. 6. M e a d o r H L , L a n e J L , S u d d ic k RP. T h e lo n g -term
A t p re s e n t, th e d ia g n o s is o f p e rio d o n ta l disease req u ires a clinical evalu atio n o f th e p a tie n t in c lu d in g visual fin d in g s, th e use o f th e p e r i o d o n t a l p r o b e , a n d r a d i o g raphs. N o test is available to evaluate dis ease activity. In sp ecific cases, a d ju n ctiv e p ro c e d u re s may also be useful. T h e id e n ti fic a tio n o f p a th o g e n i c m ic ro o rg a n is m s m ay a id in e v a lu a tin g th e p e r i o d o n t a l statu s o f special p a tie n ts . H ow ever, th e se are n o t re q u ire d fo r an a d e q u a te diagnosis o f th e co m m o n a d u lt fo rm o f c h ro n ic p e ri o d o ntitis.
re v ie w . B a s e l.
m a to ry p e r io d o n ta l d isease. A s u m m a ry o f th e c u r r e n t
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Summary
P a g e R C , S c h r o e d e r H . P e r io d o n titis in m a n
T h e A m e ric a n A cad em y o f P e rio d o n to lo g y a n d the
o f p e r i o d o n t a l p r o b i n g lie s in s e v e ra l areas. O n e is th e o n g o in g d e v e lo p m e n t o f a u to m a te d p ro b e s, w hich allow clin ician s to g a th e r d a ta w ith c a lib ra te d fo rces a n d c o m p u te r assistance, if d e sire d .54-55 O th e r areas u n d e r d e v e lo p m e n t in c lu d e evalua tio n o f te m p e ra tu re a n d vascular ch an g es as they relate to disease progressio n .
tio n a l ra d io g ra p h y , su b tra c tio n ra d io g ra p hy m ay have fu tu re value in d ia g n o sin g p e rio d o n ta l diseases. It uses a c o m p u te r ized p ro g ra m w ith d ig itized rad io g ra p h s, w h ich hav e e v a lu a te d b o n e d e n s ity a n d b o n e loss in p e rio d o n ta l disease, as well as early lesions befo re they a re id e n tified by m o re trad itio n al clinical m e th o d s.56-58H ow ever, th ese te c h n iq u e s have a draw back in th a t they re q u ire a c o n tin u o u s ev aluation o f th e b o n e a n d m ay r e q u ir e m o r e fr e q u e n t p erio d ic ra d io g ra p h s to m o n ito r th e activity o f th e disease, th u s p o sin g ra d ia tio n hazard s to th e p a tie n t a n d o p erato r.
20.
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Diagnosis is a critical step in evaluating the patient's periodontal health and aids in satisfy ing dentolegal requirements in monitoring and recordkeeping.
Diagnosing periodontal diseases Erwin P. Barrington, DDS, PhD; Myron Nevins,DDS
h e diagnosis o f p e rio d o n ta l disease re q u ire s a clinical ev aluation o f th e p a ti e n t in c lu d in g visual fin d in g s, th e u se o f th e p e r i o d o n ta l p r o b e , a n d rad io g ra p h s. N o te st is available to evalu a te d is e a s e a c tiv ity . In s p e c if ic c a s e s , ad junctive p ro c e d u re s m ay also be useful. T h e id en tificatio n o f p a th o g e n ic m icro o r g a n is m s m ay a id in e v a lu a tin g th e p e r i o d o n ta l s ta tu s o f s p e c ia l p a tie n ts . D iagnosis is a critical step in evaluating th e p a ti e n t’s p e r io d o n ta l h e a lth a n d aid s in satisfying d en to le g a l re q u ire m e n ts in m o n ito rin g a n d re c o rd k e e p in g . P e r i o d o n ta l d is e a s e s a r e th e le a d in g cause o f to o th loss in ad u lts '■» a n d are well re c o g n iz e d by th e d e n ta l p ro fessio n a n d , increasingly by th e public, as a significant h e a lth p r o b le m . F o rtu n a te ly , w ith e arly d e te c tio n a n d tre a tm e n t, it is possible fo r m ost p e o p le to re ta in th e ir te e th fo r a life tim e .4-6 T o a c h ie v e th is g o a l, ev ery o ra l ex a m in a tio n sh o u ld in c lu d e a n evaluation o f th e p e rio d o n tiu m . A sim p le p e rio d o n ta l sc re e n in g ex a m i n a t i o n c a n d e t e c t p e r i o d o n t a l d is e a s e easily in a m in im u m o f tim e. T his ex am i n a tio n s h o u ld b e sensitive to n o te devia tions fro m h e a lth a n d in c lu d e all sites. It is a c ritical ste p in ev a lu a tin g th e p a tie n t’s p e r io d o n ta l sta tu s a n d a id s in satisfying d e n to le g a l r e q u i r e m e n ts in m o n ito r in g an d re c o rd k e e p in g . It is a x io m a tic to say th a t d ise ase is a v ariatio n fro m h e a lth , yet th e c o n c e p t o f p e r io d o n ta l h e a lth m u s t b e u n d e rs to o d b efo re we can d iag n o se disease. P e rio d o n tal h e a lth m ay b e d e sc rib e d as 7:
T
T h e p e rio d o n tiu m is com p o sed of gingiva, perio d o n tal ligam ent, cem entum , and alveolar b one. T h e gingiva e x te n d s fro m the gingival m argin to the m ucogingival ju n ctio n (except on the palate) and this width becom es greater with age. In health, the color o f the gingiva is uni form a n d pale pink, b u t variation occurs as the result o f d e g re e o f keratin izatio n , p igm enta 4 60 ■ JA DA , Vol. 121, O c to b e r 1990
tion, thickness, a n d vascularity. T h e m arginal gingiva is scalloped a n d becom es th in n er coronally to m e e t th e to o th su rface w ith a knife edge m argin. Gingiva fills the interdental space w hen a d ja c e n t te e th a re in c o n ta ct, a n d this interdental gingiva consists of ora! and vestibu lar peaks co n n ec te d b e n e a th the c o n ta ct area by the col. H ealthy gingival tissue is firm and nonm obile. T he surface texture may be sm ooth or stippled. T h e gingival sulcus can be probed to approxim ately 1 m m or m ore in depth. T he p o sitio n o f th e gingival m arg in a n d gingival contour and thickness dep en d to a great extent on the position o f the associated teeth.
H e a l t h y p e r i o d o n t a l tis s u e is n o t in fla m e d .8 T h e physical c h a ra c teristics o f th e tissu e sh o w a p p r o p r ia te c o lo r, size, sh a p e, co n sisten cy , c o n to u r, a n d te x tu re . H e a l t h y ti s s u e d o e s n o t b l e e d w h e n p ro b e d gently, has n o crevicular fluid flow, a n d p ro b in g d e p th s are 1 to 3 m m . R adio g ra p h s o f b o n e tissu e show in ta c t crestal lam in a d u ra th ro u g h o u t th e d e n titio n a n d in ta c t in ter-ra d ic u la r b o n e . W hile th e severity o f p e rio d o n ta l disease m ay v ary , it is lik e ly t h a t it a ff e c ts th e m ajo rity (u p to 8 0 % ) o f th e US p o p u la tio n .1 T h e basic p a th o lo g ic al p rocesses in th e p e rio d o n ta l diseases are in flam m atio n a n d re la te d im m u n o p a th o lo g ic a l variatio n s.912 T h e p rim a ry cause o f p e rio d o n ta l disease is b a c te ria l p la q u e .13-^ T h u s , th e disease m a n ife sta tio n is th e classic h o st-b a c te ria l in t e r a c t i o n 1116. ^ w ith th e c lin ic a l sig n s b ein g th o se involved in th e in flam m ato ry process. C o n te m p o ra ry p e rio d o n tic s reco g n iz e s several fo rm s o f p e rio d o n titis , in c lu d in g som e th a t afflict c h ild re n a n d adolescents. T h o se f o u n d in th e e a rly ag e g ro u p s , as well as ad u lts, m ay a c co m p an y a systemic d is o rd e r. A lth o u g h th is a rtic le c o n c e n tr a te s its a tt e n ti o n o n th e d ia g n o s is o f c h r o n ic a d u lt p e r i o d o n ti ti s , we r e c o m m e n d a p e r io d o n ta l e x a m in a tio n fo r all y o u n g p a t i e n t s . T h e a c c e p t e d c la s s
ific a tio n 18 fo r c h ro n ic a d u lt p e rio d o n titis fro m th e A m erican A cadem y o f P eriodonto lo g y ’s C u r r e n t P ro c e d u ra l T erm in o lo g y (Fig 1-3) follows.
F ig 1 ■ H e a lth y gingiva a n d b o n e .
F ig 2 ■ T h e p r o g r e s s o f slig h t p e r io d o n ta l d is e a se .
F ig 3 ■ A d v a n c e d p e r i o d o n t a l d i s e a s e . E v e n th o u g h b o n e is d e s tro y e d , th e g in g iv al tiss u e m ay re m a in in p o s itio n a r o u n d th e te e th a n d r e p r e s e n ts th e c h a n g e s in b o th p r o b in g d e p th a n d a tta c h m e n t lo ss a s th e d is e a s e p ro g re s s e s .
A R T I C L E S ^
I. Gingivitis
III. M oderate periodontitis
In flam m atio n o f th e gingiva c h a racterized c lin ic a lly by c h a n g e s in c o lo r , g in g iv a l fo rm , p o s itio n , s u rfa c e a p p e a ra n c e , a n d p re se n c e o f b le e d in g a n d / o r e x u d ate .
A m o r e a d v a n c e d sta g e o f th e fo r g o in g c o n d itio n , w ith in c re a se d d e s tru c tio n o f th e p e rio d o n ta l stru c tu re s w ith n o ticeab le loss o f b o n e su p p o rt possibly a c c o m p an ie d by a n in c re a s e in to o th m o b ility . T h e re m ay b e f u r c a tio n in v o lv e m e n t in m u lti ro o te d tee th .
II. Slight periodontitis P ro g ressio n o f th e gingival in fla m m a tio n in to th e d e e p e r p e rio d o n ta l stru c tu re s a n d a lv eolar b o n e crest, w ith slight b o n e loss. T h e usual p e rio d o n ta l p ro b in g d e p th is 3 to 4 m m with slig h t b o n e loss o f c o n n e c tive tissu e a tta c h m e n t a n d slig h t loss o f alveolar b one.
IV. Advanced periodontitis F u rth e r p ro g re ssio n o f p e rio d o n titis w ith m a jo r loss o f alveolar b o n e su p p o rt usually a cc o m p a n ie d by in cre ase d to o th mobility. F u r c a t io n in v o lv e m e n t in m u l ti r o o t e d te e th is likely.
V . Refractory progressive periodontitis In c lu d es several unclassified types o f p eri o d o n ti ti s c h a r a c te r iz e d e i t h e r by ra p id b o n e a n d a tta c h m e n t loss, o r slow b u t co n tin u o u s b o n e a n d a tta c h m e n t loss. T h e re is re s ista n c e to n o rm a l th e ra p y , a n d th e c o n d itio n is usually asso ciated w ith gingi val in fla m m a tio n a n d c o n tin u e d p o c k e t fo rm atio n .
F ig 5 ■ P e r io d o n ta l p r o b in g d e p th s a n d a tta c h m e n t lo s s . T h e p e r i o d o n t a l p r o b e is i n s e r t e d
A p e r i o d o n t a l s c r e e n i n g e x a m i n a ti o n sh o u ld b e a fu n d a m e n ta l p a rt o f all d e n tal e x am in atio n s. W hen this su p erficial exam in a t io n re v e a ls p e r i o d o n t a l p o c k e ts o f g re a te r th a n 3 m m , b le e d in g o n p ro b in g , f u r c a tio n in v a s io n , m u c o g in g iv a l p r o b lem s, m obility, o r recession e x c e e d in g 3.5 m m , a c o m p reh en siv e evalu atio n m u st be m ad e. T h e f i r s t s t e p w h e n e x a m i n i n g th e p a tie n t is u sin g th e p ro p e r c o m p o n e n ts to establish a diagnosis. T h re e are n e e d e d : a visual e x a m in a tio n , p ro b in g e x a m in a tio n , a n d a rad io g ra p h ic e x a m in a tio n .19
a lo n g th e lo n g ax is o f th e to o th a n d m e a s u re s a 1 m m p o c k e t d e p th . N o te th a t a tta c h m e n t lo s s as
Evaluation o f clinical parameters
m e a s u r e d f r o m th e c e m e n to e n a m e l ju n c tio n to th e b a s e o f th e p o c k e t is 4 m m .
T h e f o u r c ritic a l a re a s a re th e p h y sic a l c h a r a c t e r i s ti c s o f t h e tis s u e s , p r o b i n g d e p th a n d a tta c h m e n t loss, b le e d in g with p ro b in g , an d th e results o f th e full-m outh ra d io g ra p h ic survey.
Physical characteristics of the tissues
F ig 6 ■ B le e d in g o n p r o b in g is o n e o f th e f o u r critic a l clin ical p a ra m e te rs .
g | I \ | | I | i I | j
I i I I j I
Patient examination
s w o lle n , sh in y, a n d g lis te n in g . B lo o d v e s s e ls a r e e n g o rg e d w ith e x u d a te fro m th e gingival m a rg in .
I j
Probing depth
F ig 4 ■ C h an g e s in th e p h y sical ch a ra c te ris tic s o f t h e ti s s u e o v e r t h e r i g h t c a n in e . T h e ti s s u e is
i n f l a m m a t o r y p r o c e s s m a y r e s u l t in sw elling a n d a c h a n g e in th e c o lo r o f th e ti s s u e s as p l a q u e a n d c a l c u l u s a ccu m u late. Tissues can b e co m e e n la rg e d a n d m o re fib ro tic w ith ro lle d m arg in s, a n d th e pyram id s h a p e d i n t e r d e n t a l p a p i l l a e c a n b ec o m e m o re fla tte n e d as p e rio d o n ta l disease progresses. T h e te x tu re o f th e gingiva m ay lose its stip p led c h a ra c te r a n d b eco m e sm o o th a n d g listen in g . As th e disease p ro gresses, th e gingiva b eco m e s m o re fibrotic a n d firm a n d is less g listen in g . T h e gingiva m ay even b e c o m e e n la rg e d , a n d iso lated areas o f recession may occur. T h e d im en sion o f k e ra tin iz e d a tta c h e d gingiva, with th e lo c a tio n o f th e fre e gingival m arg in , is im p o rta n t to observ e a n d re c o rd . P rogressive recessio n m ay w a rra n t co rrectiv e tre a t m e n t a n d m ay be a c o n s id e ra tio n fo r p a tie n ts w ho a re c a n d id a te s fo r o rth o d o n tic tr e a t m e n t o r m a jo r r e s to r a tiv e d e n tistry. T h e p h y sical c h a ra c te ris tic s o f th e tissu e s c h a n g e in r e la tio n to th e q u a n tity , q u a lity , d u r a t i o n , a n d in t e n s i ty o f th e in flam m ato ry process.
T h e e v a lu a tio n o f p e r i o d o n t a l tis s u e s d e p e n d s o n th e p h y sical c h a ra c te ristic s: c h a n g e s in color, size, sh ap e, consistency, te x tu re , a n d c o n to u r (Fig 4). A visual ex am in a tio n as well as p a lp atio n o f th e tissu es c a n id e n tify c h a n g e s. T h e
T h e p a th o g n o m o n ic fe a tu re o f a d u lt perio d o n titis is th e p e rio d o n ta l p o c k e t.7 T h e in flam m ato ry p ro cess can re su lt in p o c k e t f o r m a tio n , d a m a g in g th e ju n c t io n a l e p ith e liu m a n d th e s u lc u la r e p ith e liu m . S e p a ra tio n o f th e ju n c t io n a l e p ith e liu m a p p e a rs to c o in c id e w ith e p ith e lia l ap ical m i g r a t i o n , le a v in g a s p a c e f i ll e d w ith p la q u e , calc u lu s, a n d c e llu la r d e b ris.9-20-21 T h e s t a n d a r d by w h ic h th e p e r io d o n ta l p o c k e t is m e a s u r e d is th e p e r i o d o n t a l p r o b e . A n a r r o w , r o u n d p r o b e w ith b lu n te d p o in t a n d m ille m e te r ca lib ra tio n sh o u ld b e used. R e c o rd in g s u su ally in c lu d e th e m esial a n d distal in te rp ro x im a l a n d facial o r ling u al a sp e c t o f e a c h to o th . It is im p o rta n t to p ro b e directly u n d e r th e c o n ta c t p o in t, m a in ta in in g th e p ro b e p arallel to th e lo n g axis o f th e to o th (Fig 5 ). S uch re c o rd in g s allow a site-specific a n d g e n e ra liz e d evaluatio n o f th e p a tie n t-7-21-24 T h e use o f th e p e rio d o n ta l p ro b e elucid ates th e physical ch aracteristics as well as th e d e p th o f th e p o c k e t. P r e s e n c e o f a p o c k e t d e p ic ts p a st d e s tru c tio n a n d d o es n o t d e te rm in e th e c u r r e n t activity o f th e disease p ro cess.7-19-22-2527 In g e n e ra l, a perio d o n ta l p ro b in g d e p th is m e a s u re d from th e g in g iv a l m a r g in to th e b a s e o f th e p o c k e t w ith 1 to 3 m m c o n sid e re d w ithin th e ra n g e o f h e a lth . H o w ev er, b le e d in g a n d flu id e x u d a te w ith p r o b in g in d ic a te JADA, Vol. 121, O cto b er 1990 ■ 461
J j
■
J I I
j j j 1 I f
j j j j
s I f 1
I j * I
A R T I C L E S
p a th o s is , re g a r d le s s o f th e p ro b in g d e p th .7-28-30 T h e d e p th re c o rd e d m ay n o t accurately r e f l e c t t h e h i s t o l o g i c a l d e p t h o f th e p o c k e t, b e c a u s e th e p r o b in g fo rc e a n d a n g u la tio n , c o u p le d w ith p a tie n t sensitivity levels a lt e r th e r e a d in g s .7-25-31-35 B a se lin e p ro b in g d a ta sh o u ld b e c o lle c te d b e fo re a n d a fte r in itial d e b rid e m e n t th erap y , to m e a s u re th e im p ro v e m e n t a tta in e d w ith n o n su rg ic a l p ro c e d u re s. B o th u n d e r- a n d o ver-probing can o c c u r a n d a lte r th e p e r ce p tio n o f th e tru e severity o f th e disease. A tta c h m e n t loss is a relative n ew co m er to p e r io d o n ta l m e a s u re m e n ts . 19.22.2» T h is m e a s u re m e n t— ta k e n fro m a fix ed p o in t, u su ally th e c e m e n to e n a m e l ju n c t io n , to th e b a s e o f th e p o c k e t— in d ic a te s h o w m u c h a c tu a l loss o f p e r io d o n ta l a tta c h m e n t h a s o c c u r r e d . T h is m e a s u r e m e n t in d ic a te s th e e x te n t o f p r io r d e stru c tio n , n o t disease pro g ressio n . It is c o n sid e re d a m o r e a c c u r a t e b a s e l in e o f th e d is e a s e state. T h ese m e a su re m e n ts a re invaluable in c lin ic a l r e s e a r c h , b e c a u s e th e y u s e d fixed re fe re n c e p o in ts fo r fu tu re c o m p a r isons. Bleeding upon probing T h e p ro b in g ex am in atio n may elicit b le e d in g w ith o n ly a g e n t l e p r o b i n g f o r c e , w hich in d icates in flam m a tio n b u t is a lim ite d p re d ic to r o f p e rio d o n ta l disease activ ity (Fig 6 ).36-37 It is p o ssib le to have d e e p p o c k e t d e p th in th e ab se n c e o f b leed in g , b u t it d o es n o t in d ic a te th e ab sen ce o f dis ease. B leeding can be m o d ifie d by systemic m e d ic a tio n , in c lu d in g a n tib io tic s , w h ich f u r th e r affe c ts its d ia g n o s tic lim ita tio n s. T h e a c c e p te d fo rce to evaluate fo r b le e d in g p o in ts is a p p ro x im a te ly 20 to 25 lb , ap p ro x im ately th e fo rce u sed to in se rt th e p e r io d o n ta l p ro b e u n d e r th e fin g e rn a il bed.
te e th . A p a n o r a m ic r a d i o g r a p h c a n be u s e d as a s u p p le m e n ta l d ia g n o s tic to o l, b u t is n o t a d e q u a te fo r p e rio d o n ta l d iag no sis. 7-24 T h e d a ta o f th e se in v estig a tio n s sh o u ld b e c o rre la te d to re a c h a m e a n in g ful d iagnosis a n d to p lan a p p ro p ria te tre a t m e n t.
Diagnosing disease breakdown Is it possible to d iag n o se th e state o f active p e rio d o n ta l breakdow n? T h is q u e stio n has b e e n th e su b ject o f intensive re se a rc h fo r m any years a n d th e re are in d ica tio n s th at t h i s e lu s iv e c o n c e p t m a y y e t b e a c h ie v e d .722,4° Ideally , a to tally o b jec tiv e d ia g n o s tic te s t w o u ld b e a g r e a t a s s e t, a lth o u g h n o such test cu rre n tly exists. T h e q u e s tio n s o f how o fte n , h o w ra p id , a n d how lo n g th e active lesio n is in p ro g re ss a re n o t resolved a n d a re o p e n to investiga tio n . C onsequently, th e c u rr e n t ev aluation o f p e rio d o n ta l disease is b ased o n m an y diag nostic tools a n d clinical ju d g m e n ts as well as c lin ic a l e x p e r ie n c e s .7-24 N o n e th e le s s , a d d itio n a l d ia g n o s tic a id s a re a v a ila b le a n d c a n be view ed as a d ju n c tiv e tests at this tim e. Adjunctive tests
Radiographic techniques In a d d itio n to th e p h y sic a l c h a r a c te r is tics— p ro b in g d e p th s , a tta c h m e n t loss, a n d b le e d in g o n p ro b in g , a n o th e r im p o rta n t diagnostic aid is th e ra d io g ra p h (Fig 7). A n in itial fu ll-m o u th series o f in tra o ra l ra d io g ra p h film s, in c lu d in g bitew ings a re n e e d e d to e v a lu a te t h e o s s e o u s tissu es. 24.s8.39 T h e p a ra lle lin g te c h n iq u e can p r o d u c e a m e a n in g f u l i n t r a o r a l r a d i o g ra p h . T h e tw o-dim ensional ra d io g rap h is a re d u c tio n o f a th re e -d im e n sio n a l to o th a n d alveolar process a n d illustrates th e loss o f in tra p ro x im a l a n d in te rra d ic u la r b o n e , b u t may be m islead in g in d e te rm in in g th e loss o f b o n e o n th e ra d ic u la r su rfa c e o f 46 2 ■ JADA, Vol. 121, O ctob er 1990
A d d itio n al testing m e th o d s a re available to h e lp establish th e diagnosis o f p e rio d o n ta l diseases. T h e re c o g n itio n o f p e rio d o n ta l diseases as infectio u s has fo cu sed research in th e id e n tificatio n o f specific p ath o g en s. F o r years, p e rio d o n ta l disease was c o n sid e r e d r e l a t e d to th e m a s s o f b a c t e r i a l p la q u e o v e rw h e lm in g th e h o s t d e fe n s e m ech a n ism .4' T h is c o n c e p t o f n onspecific p la q u e h as re c e n tly b e e n c h a lle n g e d by r e s e a r c h id e n t i f y i n g s p e c i f ic s p e c ie s re la te d to th e d isease.42 T h ese species iso la te d a re m ostly g ra m -n e g a tiv e a n e ro b ic ro d s a n d in c lu d e Bacteroides g in g iv a lis, Intermedius, Actinobacillus actinomycetemcomitans a n d o th e rs.43-45
Culturing. O rg an ism s may be c u ltu re d an d
isolated in a la b o ra to ry settin g a n d selec tive m e d ia can be used to h e lp identify var io u s s p e c i e s . 740 O n e s id e b e n e f i t o f c u ltu rin g te c h n iq u e s is th a t an tib io tic sen sitivity ca n be d e te r m in e d fo r th e a p p ro p riate an tib io tic if sign ifican t tre a tm e n t is w a rra n te d . B acterio lo g ic te stin g la b o ra to ries a re av ailable c o m m e rc ia lly a t several u n iv e rsitie s . U n fo rtu n a te ly , d is e a se p r o g ression c a n n o t be p re d ic te d o n th e basis o f id e n tific a tio n o f th e p u tativ e m ic ro o r ganism s. Darkfield and phase contrast microscopy.
T h e se te c h n iq u e s have b e e n u se d m ainly as c h a irsid e m e th o d s to id en tify b acterial m o rp h o ty p e s , a lth o u g h th e y have h a d a w eak c o rre la tio n with th e p re se n c e o f dis ease.47-48 It is d ifficult to relate th e fin d in g o f s p ir o c h e te m o b ility to c h r o n ic a d u lt p e r io d o n titis as g ra m -n e g a tiv e ro d s a re b elieved to b e th e etiologic agent. M icroscopic m o n ito rin g has b e e n used in c o n ju n c t io n w ith m a i n te n a n c e a fte r p e r i o d o n t a l t r e a t m e n t a n d h a s sh o w n slig h t c o r r e la tio n b e tw e e n sp e c ific m o r p h o ty p e s a n d th e p re s e n c e o f in fla m m a tio n . H o w ev er, m ic ro s c o p ic m o n ito r in g has n e v e r b e e n effective fo r th e evaluation o f p e rio d o n ta l disease activity o r as a p re d ic to r fo r disease activity. DNA probe. T his la b o ra to ry to o l identifies
sp e c ific s e q u e n c e s o f n u c le ic a cid s th a t c o m p r is e t h e D N A c h r o m o s o m e s a n d id en tifies individual m icro o rg anism s, with a h ig h d e g re e o f sp ecific ity a n d sensitiv ity.49-51 At this tim e, tests exist fo r ju s t th re e m i c r o o r g a n is m s , A c tin o b a c illu s actinomycetemcomitans, B gingivalis, a n d B inter medius, b u t ad d itio n al p ro b e s m ay so o n be available. In th is te c h n iq u e , a subgingival p la q u e sam ple is se n t to a c o m m erical lab o ra to ry fo r analysis. T h e test is sim p le to use in a d e n ta l office a n d results a re fairly a c c u ra te w h e n c o r r e la te d w ith c u ltu rin g
A R T I C L E S
te ch n iq u es. H ow ever, this te c h n iq u e sam ples fo r only th re e m icro o rg an ism s a n d as least six to eig h t have b e e n strongly im p li cated in p e rio d o n ta l disease activity. T his te c h n iq u e n e ith e r p red icts disease activity n o r allows sensitivity testin g o f antibiotics. Cervicular fluid assay. Tissue d estru c tio n is critical.7-2'228-40 C o n n ectiv e tissue a n d b o n e u n d e rg o d e s tr u c tio n in p e r io d o n ta l dis eases. As tissue is d estro y ed by th e in flam m a to ry a n d im m u n o lo g ic p ro c e sse s, th e d estru c tiv e activity o f th e disease c a n b e m o n ito re d by v arious enzym e analyzes o f d e g ra d a tio n p ro d u c ts fo u n d in th e g in g i val c e rv ic u la r flu id .7-52-53 M e a s u re m e n t o f c e rv ic u la r flu id flow o fte n in d ic a te s g in givitis, b u t does n o t c o rre la te as well with p erio d o n titis. Adjunctive periodontal probing. T h e fu tu re
T h e a u th o rs th a n k Dr. R o b e rt G. S c h a llh o rn fo r his advice a n d g u id a n c e in th e p r e p a r a tio n o f th is p a p e r a n d to M rs. M aria E q u ih u a fo r s e c re ta ria l assistan ce.
21. P a g e RC, S c h r o e d e r H . P a th o g e n e s is o f in fla m A m e ric a n D e n ta l A sso ciatio n a r e in v e stig atin g d e v e lo p m e n t o f a P e rio d o n ta l S c r e e n in g E x a m in a tio n w h ich
w o rk . L a b In v est 1976;4:235. 22. H a ffa je e AD, S o cran sk y SS, G o o d so n JM . C lin i
will p ro v id e d e n tis ts w ith an effectiv e a n d ra p id m e an s
cal p a r a m e te r s as p r e d ic to r s o f d e s tru c tiv e p e r io d o n ta l d isea se activity. J C lin P e r io d o n to l 1983;10:257.
to d e t e c t p e r i o d o n ta l d is e a s e s . A ll m e m b e r s o f th e d e n ta l p ro fessio n will b e g iven full in fo rm a tio n o n this e x a m in a tio n w h e n d e v e lo p m e n t is c o m p le te . D r. B a rrin g to n is in p riv a te p ra c tic e a n d p ro fe s s o r o f P e rio d o n tic s , U niversity o f Illin o is a t C h ic ag o , d e p a rt m e n t o f p e r io d o n tic s , B o x 6 9 9 8 , C h ic a g o , IL 60680.
C lin P e r io d o n to l 1984; 11:21. 24. G u id e lin e s fo r p e r io d o n ta l th e ra p y . In : A m e ri ca n A cad em y o f P e rio d o n to lo g y , ed s. C u r r e n t
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D r. N evins is also in p riv ate p ra c tic e a n d is th e co-direct o r o f th e I n s tit u te f o r A d v a n c e d D e n ta l S tu d ie s in S w am pscott, MA. S e n d re q u e s ts fo r re p rin ts to Dr. B ar
it m e a n ? J C lin P e rio d o n to l 1980;7:165.
rin g to n .
26. G r e e n s te in G. T h e s ig n ifican ce o f p a c k e t d e p th m e a s u r e m e n ts . C o m p e n d C o n tin E d u c D e n t 1984;5:49. 27. C a to n J G , G re e n s te in G , P o is o n AM. D e p th o f
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p e rio d o n tic s .
S t.
L o u is :
L o e H . E p id e m io lo g y o f p e r i o d o n ta l d is e a se .
Adjunctive radiography. In a d d itio n to trad i
------------------- J!*OA------------------
23. S o cran sk y SS, H affaje e A D, G o o d so n JM , L in d h e J . N ew c o n c e p ts o f d e s tru c tiv e p e r io d o n ta l d is e a se . J
d u r a l T e rm in o lo g y . 5 th e d . C h ic a g o : T h e A m e r ic a n A cad em y o f P e rio d o n to lo g y ; 1988. 25. L istg a rte n MA. P e rio d o n ta l p ro b in g : W h a t d o e s
o d o n to l 1982;53:539. 6. M e a d o r H L , L a n e J L , S u d d ic k RP. T h e lo n g -term
A t p re s e n t, th e d ia g n o s is o f p e rio d o n ta l disease req u ires a clinical evalu atio n o f th e p a tie n t in c lu d in g visual fin d in g s, th e use o f th e p e r i o d o n t a l p r o b e , a n d r a d i o g raphs. N o test is available to evaluate dis ease activity. In sp ecific cases, a d ju n ctiv e p ro c e d u re s may also be useful. T h e id e n ti fic a tio n o f p a th o g e n i c m ic ro o rg a n is m s m ay a id in e v a lu a tin g th e p e r i o d o n t a l statu s o f special p a tie n ts . H ow ever, th e se are n o t re q u ire d fo r an a d e q u a te diagnosis o f th e co m m o n a d u lt fo rm o f c h ro n ic p e ri o d o ntitis.
re v ie w . B a s e l.
m a to ry p e r io d o n ta l d isease. A s u m m a ry o f th e c u r r e n t
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P a g e R C , S c h r o e d e r H . P e r io d o n titis in m a n
T h e A m e ric a n A cad em y o f P e rio d o n to lo g y a n d the
o f p e r i o d o n t a l p r o b i n g lie s in s e v e ra l areas. O n e is th e o n g o in g d e v e lo p m e n t o f a u to m a te d p ro b e s, w hich allow clin ician s to g a th e r d a ta w ith c a lib ra te d fo rces a n d c o m p u te r assistance, if d e sire d .54-55 O th e r areas u n d e r d e v e lo p m e n t in c lu d e evalua tio n o f te m p e ra tu re a n d vascular ch an g es as they relate to disease progressio n .
tio n a l ra d io g ra p h y , su b tra c tio n ra d io g ra p hy m ay have fu tu re value in d ia g n o sin g p e rio d o n ta l diseases. It uses a c o m p u te r ized p ro g ra m w ith d ig itized rad io g ra p h s, w h ich hav e e v a lu a te d b o n e d e n s ity a n d b o n e loss in p e rio d o n ta l disease, as well as early lesions befo re they a re id e n tified by m o re trad itio n al clinical m e th o d s.56-58H ow ever, th ese te c h n iq u e s have a draw back in th a t they re q u ire a c o n tin u o u s ev aluation o f th e b o n e a n d m ay r e q u ir e m o r e fr e q u e n t p erio d ic ra d io g ra p h s to m o n ito r th e activity o f th e disease, th u s p o sin g ra d ia tio n hazard s to th e p a tie n t a n d o p erato r.
20.
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