Jan Lindhe. Clinical Periodontology

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EXAMINATION OF PATIENTS WITH PERIODONTAL DISEASE • 4

Fig. 18-3. Schematic drawing illustrating the histologic

features of periodontal disease. Note the infiltrated con

nective tissue area (ICT).

Fig. 18-4. (a-c) Clinical status of a 55-year-old male with periodontal disease.

are present, inflammatory lesions residing in the overt

portion of the gingiva are distinguished by probing in

the superficial marginal tissue. When the infiltrate

resides in sites with deepened pockets and attachment

loss, the inflammatory lesion in the apical part of the

pocket must be identified by probing to the bottom of

the deepened pocket.

Bleeding on probing:

a blunt periodontal probe is in-

serted to the "bottom" of the gingival pocket and is

moved gently along the tooth (root) surface (Fig. 18-5).

If bleeding is provoked by this instrumentation, the

site examined is considered inflamed.

Fig. 18-6 illustrates the chart used to identify gingi-

val sites which at the initial examination of the 55-

year-old patient referred to above were found to bleed

on probing. Each tooth in the chart is represented by a

square and each tooth surface by a triangle. The upper

triangle represents the palatal/lingual gingival

unit,

the bottom triangle the buccal unit and the re

maining

fields the two approximal gingival units. A

cross is

inserted in the fields of the chart which corre-

406 • CHAPTER

Fig. 18-5. Pocket probing used to identify gingival in-

flammation. A site is considered inflamed if bleeding is

provoked by gentle probing to the bottom of the

pocket.

Sites with gingivitis

Fig. 18-6. The gingivitis chart of the patient seen in Fig. 18-4.

spond to the inflamed gingival units. The mean gin-

givitis score is given as a percentage figure. In the

present patient (Fig. 18-4a-c), 27 out of a total number

of 52 gingival units in the maxilla bled on probing. The

gingivitis score for the maxillary dentition is thus 50%.

The corresponding score for the mandibular dentition

59%. This method of charting not only serves as a

means of documenting areas of health and disease in

the dentition but similar charting during the course of

therapy will disclose sites which turn healthy or re-

main inflamed.

THE PERIODONTAL LIGAMENT —

THE ROOT CEMENTUM

In order to evaluate the amount of tissue lost in peri-

odontal disease and also to identify the apical exten-

sion of the inflammatory lesion, the following pa-

rameters should be recorded:

pocket depth (probing depth)

attachment level (probing attachment level)

furcation involvement

tooth mobility

Assessment of pocket depth

The pocket (-probing-) depth, i.e. the distance from the

gingival margin to the bottom of the gingival pocket,

measured by means of a graduated probe (Fig. 18-7).

The pocket depth should be assessed at each surface

of all teeth in the dentition. In the periodontal chart

(

Fig. 18-10) it may be sufficient to identify only the

deepest value recorded at each tooth surface. Pocket

depth values of < 4 mm may be excluded from the

chart since such pockets can be regarded as falling

within normal variations.

Results from pocket depth measurements will only

in rare situations (when the gingival margin coincides

with the cemento-enamel junction) give proper infor-

mation regarding the extent of loss of probing attach-

ment. For example, an inflammatory edema may

cause a swelling of the free gingiva resulting in a

coronal displacement of the gingival margin without a

concomitant migration of the dentogingival epithe-

lium to a level apical to the cemento-enamel junction.

In such a situation a pocket depth exceeding 3-4 mm

represents a "pseudopocket". In other situations, an

obvious loss of attachment may have occurred with-

out a concomitant increase of the pocket depth. A

situation of this kind is shown in Fig. 18-7 at the buccal

aspect of teeth 21 and 22 (two-digit systems; FDI 1970)

where recessions of the gingiva can be seen.

Assessment of attachment level

Attachment levels may be assessed by means of a

graduated probe and expressed as the distance in mm

from the cemento-enamel junction to the bottom of the

probeable gingival pocket. The longest distance for

each tooth surface is recorded and may be included in

the periodontal chart.

EXAMINATION OF PATIENTS WITH PERIODONTAL DISEASE •

407

Fig. 18-7. Measurement of probing depth. Note the gin

gival recession at the buccal aspect of teeth 21 and 22.

Fig. 18-8. (a) In the presence of an inflammatory cell infiltrate (ICT) in the gingiva, the probe penetrates apically to

the bottom of the histologic pocket. (b) Following successful therapy the swelling is reduced (R = recession) and the

cell infiltrate is replaced by collagen. The probe fails to reach the apical part of the dentogingival epithelium. CEJ =

cemento-enamel junction. PPD = probing pocket depth. PAL = probing attachment level, R = recession. Gain PAL =

recorded-false-gain of attachment ("clinical attachment

Errors inherent in periodontal probing

The distances recorded in a periodontal examination

using a periodontal probe have generally been as-

sumed to represent a fairly accurate estimate of the

pocket depth or attachment level at a given site. In

other words, the tip of the probe has been assumed to

identify the level of the most apical cells of the dento-

gingival epithelium. Results from research published

in the 1970s have demonstrated, however, that this is

seldom the case (Saglie et al. 1975, Listgarten et al.

1976, Armitage et al. 1977, Ezis & Burgett 1978, Spray

et al. 1978, Robinson & Vitek 1979, van der Velden

1979, Magnusson & Listgarten 1980, Polson et al.

1980). Listgarten (1980) listed a variety of factors

which influence the result of a measurement made

with a periodontal probe. These factors include (1) the

thickness of the probe used, (2) malposition of the

probe due to anatomic features such as the contour of

the tooth surface, (3) the pressure applied on the in-

strument during probing, and (4) the degree of inflam-

matory cell infiltration in the soft tissue and accompa-

nying loss of collagen. Listgarten suggested that "a

distinction should be made between the histological

and the clinical pocket depth to differentiate between

the depth of the actual anatomic defect and the meas-

urement recorded by the probe".

Measurement errors depending on factors such as

the thickness of the probe, the contour of the tooth

surface and improper angulation of the probe can be

reduced or avoided by the selection of a proper instru-

ment and careful management of the examination

procedure. More difficult to avoid, however, are errors

resulting from variations in probing force and the

extent of inflammatory alterations of the periodontal

tissues. As a rule, the greater the probing force, the

deeper the penetration of the probe into the tissue. In

this context it should be realized that in investigations

designed to disclose the force used by different clini-

cians, the probing force was found to range from 3 to

130 g (Gabathuler & Hassell 1971, Hassell et al. 1973),

and also to differ by as much as 2:1 for the same dentist

408 • CHAPTER 18

Fig. 18-9. A periodontal probe inserted into the buccal furcation area of a mandibular molar. A furcation involve

ment of degree 2 was found.

Fig. 18-10. Periodontal chart including the data ob-

tained from the examination of the patient presented in

Fig. 18-4.

from one examination to another. In order to exclude

measurement errors related to the effect of variations

in probing force, so-called pressure sensitive probes

have been developed. Such probes will enable the

examiner to probe with a predetermined force (van der

Velden & de Vries 1978, Vitek et al. 1979, Poison et

al.

1980). However, over and underestimation of the

true" pocket depth or attachment level may also

occur when this type of probing device is employed (

Armitage et al. 1977, Robinson & Vitek 1979, Poison

a1.1980). Thus, when the connective tissue subjacent

the pocket epithelium is infiltrated by inflammatory

cells, the periodontal probe will most certainly pene-

trate beyond the apical termination of the dentogingi-

val epithelium. This results in an overestimation of the

"true" depth of the pocket. Conversely, when the in-

flammatory infiltrate decreases in size following suc-

cessful periodontal treatment, and a concomitant

deposition of new collagen takes place within the

previously inflamed tissue area, the dentogingival

tissue will become more resistant to penetration by the

probe. The probe may now fail to reach the apical

termination of the epithelium. This results in an un-

derestimation of the "true" pocket depth or attach-

ment level. The magnitude of the difference between

the probing measurement and the histologic "true"

pocket depth (Gain PAL; Fig. 18-8b) may range from

fractions of a millimeter to several millimeters (List-

garten 1980).

From this discussion it should be understood that

reduction of pocket depth following periodontal treat-

ment and/or gain of attachment, assessed by peri-

odontal probing, are not necessarily signs of forma-

tion of a new connective tissue attachment in the

bottom of the previous pocket. Rather, such a change

may merely represent a resolution of the inflamma-

tory process and may thus occur without an accom-

panying attachment gain (Fig. 18-8). In this context it

should be realized that the terms "pocket depth" and

"gain and loss of attachment" in modern literature

have often been changed to the more exact terms

probing depth" and "gain and loss of clinical attach-

ment" or "probing pocket depth" and "probing at-

tachment level".

Current knowledge of the histopathology of peri-

odontal lesions and healing of such lesions has thus

resulted in an altered concept regarding the validity

of periodontal probing. However, despite difficulties

interpreting the proper significance of pocket depth

and attachment level measurements, such determina

tions still give the clinician a useful estimate of the

degree of disease involvement, and particularly so

EXAMINATION OF PATIENTS WITH PERIODONTAL DISEASE • 409

Fig. 18-11. Radiographic status of the patient presented in Fig. 18-4.

when the information obtained is related to other

findings of the examination procedure such as "bleed

ing on probing", and alveolar bone height alterations.

Assessment of furcation involvement

In the progression of periodontal disease around

multi-rooted teeth, the destructive process may in-

volve the supporting structures of the furcation area

(

Fig. 18-9). Elaborate therapeutic techniques must

often be used to treat such

furcation involvements

prop

erly. Therefore, the precise identification of the pres-

ence and extension of periodontal tissue breakdown

within the furcation area is of importance for proper

diagnosis and treatment planning.

Furcation involvements may be classified into:

Degree 1: Horizontal loss of supporting tissues not

exceeding

of the width of the tooth.

Degree 2: Horizontal loss of supporting tissues ex-

ceeding

of the width of the tooth, but not encom

passing the total width of the furcation area.

Degree 3: Horizontal "through-and-through" de-

struction of the supporting tissues in the

furcation.

The degree of furcation involvement is presented in

the periodontal chart (Fig. 18-10) together with a de-

scription of which tooth surface the involvement has

been identified on (e.g. tooth 26: m, b, d 2; tooth 48: b

2; tooth 36: b 2). A detailed discussion regarding diag

nosis of furcation involvements and treatment of fur-

cation-involved teeth is presented in Chapter 28.

Assessment of tooth mobility

The continuous loss of the supporting tissues in pro-

gressive periodontal disease may result in increased

tooth mobility. Increased tooth mobility may be clas-

sified in the following way:

Degree 1: Movability of the crown of the tooth 0.2-1

mm in horizontal direction

Degree 2: Movability of the crown of the tooth exceed-

ing 1 mm in horizontal direction

Degree 3: Movability of the crown of the tooth in

vertical direction as well.

It must be understood that plaque-associated peri-

odontal disease is not the only cause of increased tooth

mobility. For instance, overloading of teeth and

trauma may result in tooth hypermobility. Increased

tooth mobility can frequently also be observed in

conjunction with periapical lesions, immediately fol-

lowing periodontal surgery, etc. From a therapeutic

point of view it is important, therefore, to assess not

only the degree of increased tooth mobility but also

the cause of the observed hypermobility (see Chapters

15 and 27).

All data collected in conjunction with measure-

ments of pocket (-probing-) depth as well as from the

assessments of furcation involvement and tooth mo-

bility are included in the periodontal chart (Fig. 18-10).

The various teeth in this chart are denoted according

to the two-digit system adopted by FDI in 1970.

THE ALVEOLAR BONE

Radiographic analysis

The height of the alveolar bone and the outline of the

bone crest are examined in the radiographs in Fig.

18-

11. The radiographs provide information of the

height

and configuration of the interproximal alveolar

bone.

Covering structures (bone tissue, teeth) often

make it

difficult to identify properly the outline of the

buccal

and lingual alveolar bone crest. The analysis of

the

radiographs must therefore be combined with a

detailed evaluation of the pocket depth and attach-

ment level data in order to arrive at a correct estimate

concerning "horizontal" and "vertical" bone loss.

Following active treatment, patients must be en-

rolled in a follow-up and maintenance care program

aimed at preventing recurrence of periodontal dis-

ease. This program includes regular reexaminations

to study the periodontal conditions. Such reexamina-

410 • CHAPTER. 18

Fig. 18-12. The Eggen device for obtaining "stand

ardized" radiographs.

tions often require repeated radiographic analysis of

teeth and jaws at given time intervals. To enable mean

ingful comparative analysis, a radiographic technique

should be used which produces periodic reproducible

roentgenograms. A technique of this kind has been

described by, for example, Eggen (1969) (Fig.

18-12).

Sounding

In order to arrive at a correct diagnosis with respect to

the alveolar bone level, the presence of angular bony

defects and interdental osseous craters etc., an addi-

tional method, called "sounding", may be used. Fol-

lowing local anesthesia the periodontal probe is in-

serted into the pocket. The tip of the probe is forced

through the supraalveolar connective tissue to make

contact with the bone and the distance from the ce-

mento-enamel junction to the bone level is assessed in

mm.

DIAGNOSIS OF PERIODONTAL

LESIONS

The information regarding the condition of the vari

ous

periodontal structures (the gingiva, the periodontal

ligament, the root cementum and the alveolar bone)

which has been obtained through the compre

hensive

examination presented above should form the

basis for

a proper assessment of the periodontal con

dition (Fig.

18-13). It is advantageous to give each

tooth in the

dentition an individual "diagnosis". Four

different "

diagnoses" may be used:

Gingivitis

This diagnosis is used when one or several gingival

units around a particular tooth are found to bleed on

probing. Probing pocket depth and probing attach-

ment level measurements and the radiographic analy-

sis

must

fail

to indicate loss of supporting tissues.

Pseudopockets" may be present.

Fig. 18-13. The conditions of the periodontal tissues around each individual tooth in the dentition are described us

ing different criteria (periodontal charting, radiographic analysis) and diagnosis.

EXAMINATION OF PATIENTS WITH PERIODONTAL DISEASE • 411

Periodontitis levis

(

overt periodontitis)

The pocket depth and attachment level measurements

and radiographic analysis indicate an even ("horizon-

tal") loss of supporting tissues not exceeding one third

of the length of the root. Inflammation must be pre-

sent, i.e. "bleeding on probing" will occur when the

site is probed to the "bottom of the pocket".

Periodontitis gravis (

advanced periodontitis)

Pocket depth and attachment level measurements and

the radiographic analysis indicate an even ("horizon-

tal") loss of supporting tissues exceeding one third of

the length of the root. "Bleeding on probing" to the

bottom of the pocket" must be present.

A supplementary diagnosis

periodontitis complicate

is used

when an angular bony defect (infrabony pocket,

interdental osseous crater) is present adjacent to a

tooth, and

for a multi-rooted tooth in which furcation involve-

ments of degree 2 or 3 have been identified.

A chart of diagnosis is shown in Fig. 18-14. This par-

ticular chart refers to the patient whose clinical status

is shown in Fig. 18-4a-c, periodontal chart in Fig. 18-10

and radiographic status in Fig. 18-11. The various

teeth have received the diagnoses described in Fig.

18-14.

412 • CHAPTER 18

Periodontal diagnosis

Gingivitis

Periodontitis levis

Periodontitis gravis

... et complicata

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

Gingivitis

Periodontitis levis

Periodontitis gravis

... et complicata

Fig.

18-14.

Chart of diagnosis describing the patient in Fig. 18-4.

Sites with plaque

Fig.

18-15.

The plaque and gingivitis chart of the patient presented in Fig. 18-4.

ORAL HYGIENE STATUS

In conjunction with examination of the periodontal

tissues, the patient's oral hygiene must also be evalu-

ated. Absence or presence of plaque on each tooth

surface in the dentition is recorded. The bacterial de-

posits may be stained with a disclosing solution to

facilitate their detection. The presence of plaque is

marked in appropriate fields in the plaque chart

shown

in Fig. 18-15. The mean plaque score for the dentition

is given as a percentage value in correspon

dence with

the system used for gingivitis.

Alterations with respect to the presence of plaque

and gingival inflammation are illustrated in a simple

way by the repeated use of the combined plaque and

gingivitis chart (Fig. 18-15) during the course of treat-

ment.

In addition to the assessment of plaque, retention

factors for plaque, such as supra and subgingival

calculus and defective margins of dental restorations,

should also be identified and included in the peri-

odontal chart.

CONCLUSION

The methods described above for the examination of

patients with respect to periodontal disease provide a

EXAMINATION OF PATIENTS WITH PERIODONTAL DISEASE • 413

thorough analysis of the presence, extent and severity

of the disease in the dentition. The correct diagnosis

for each individual tooth should form the basis for the

treatment planning of the individual case.

REFERENCES

Armitage, G.C., Svanberg, G.K. & Loe, H. (1977). Microscopic

evaluation of clinical measurements of connective tissue at-

tachment level.

Journal of Clinical Periodontology

4, 173-190.

Eggen, S. (1969). Standardisered intraoral rontgenteknik.

Sveriges Tandldkareforbunds Tidning

17, 867-872.

Ezis, I. & Burgett, F. (1978). Probing related to attachment levels

on recently erupted teeth.

Journal of Dental Research

57, Spec

Issue A 307, Abstract No. 932.

Gabathuler, H. & Hassell, T. (1971). A pressure sensitive peri-

odontal probe.

Helvetica Odontologica Acta 15,

114-117.

Hassell,

T.M., Germann, M.A. & Saxer, V.P. (1973). Periodontal

probing: investigator discrepancies and correlations between

probing force and recorded depth.

Helvetica Odontologica Acta

17, 38-42.

Listgarten, M.A. (1980). Periodontal probing: What does it

mean?

Journal of Clinical Periodontology

165-176.

Listgarten, M.A., Mao, R. & Robinson, P.J. (1976). Periodontal

probing and the relationship of the probe tip to periodontal

tissues.

Journal of Periodontology

47, 511-513.

Magnusson, I. & Listgarten, M.A. (1980). Histological evaluation

of probing depth following periodontal treatment.

Journal of

Clinical Periodontology

7, 26-31.

Page, R.C. & Schroeder, H.E. (1976). Pathogenesis of chronic

inflammatory periodontal disease. A summary of current

work.

Laboratory Investigations 33,

235-249.

Poison, A.M., Caton, J.G., Yeaple, R.N. & Zander, H.A. (1980).

Histological determination of probe tip penetration into gin-

gival sulcus of humans using an electronic pressure-sensitive

probe.

Journal of Clinical Periodontology

7, 479-488.

Robinson, P.J. & Vitek, R.M. (1979). The relationship between

gingival inflammation and resistance to probe penetration.

Journal of Periodontal Research

14, 239-243.

Saglie, R., Johansen, J.R. & Flotra, L. (1975). The zone of com-

pletely and partially destructed periodontal fibers in patho-

logical pockets.

Journal of Clinical Periodontology 2,

198-202.

Spray, J.R., Garnick, J.J., Doles, L.R. & Klawitter, J.J. (1978).

Microscopic demonstration of the position of periodontal

probes.

Journal of Periodontology

49, 148-152.

van der Velden, U. (1979). Probing force and the relationship of

the probe tip to the periodontal tissues.

Journal of Clinical

Periodontology 6,

106-114.

van der Velden, U. & de Vries, J.H. (1978). Introduction of a new

periodontal probe: The pressure probe.

Journal of Clinical

Periodontal< <g y 5,

188-197.

Vitek, R.M., Robinson, P.J. & Lautenschlager, E.P. (1979). Devel-

opment of a force-controlled periodontal instrument.

Journal of

Periodontal Research

14, 93-94.

CHAPTER 19

Treatment Planning

JAN LINDHE, STURE NYMAN AND NIKLAUS P. LANG

Screening for periodontal disease

Diagnosis

Treatment planning

Initial treatment plan

Case presentation

Initial (cause-related) therapy

Re-evaluation

Planning of additional therapy

Additional (corrective) therapy

Supportive periodontal therapy

Case reports

Caries and periodontal diseases are opportunistic in-

fections associated with biofilm formation on the sur-

faces of teeth. Factors such as bacterial specificity and

pathogenicity as well as the disposition of the individ-

ual for disease, e.g. local and general resistance, may

influence the onset, the rate of progression and clinical

character of the plaque-associated dental disorders.

Findings from animal experiments and longitudinal

studies in humans, however, have demonstrated that

treatment, including the elimination or the control of

the plaque infection and the introduction of careful

plaque control measures, in most, if not all, cases

results in dental and periodontal health. Even if health

cannot always be achieved and maintained, the arrest

of disease progression following treatment must be

the

goal of modern dental care.

The treatment of patients affected by caries and

periodontal disease, including symptoms of associ-

ated pathologic conditions such as pulpitis, periapical

periodontitis, marginal abscess, tooth migration, etc.,

may from a didactic point of view be divided into

three

different stages: initial, cause-related therapy,

additional therapeutic measures (corrective phase)

and supportive periodontal therapy (or maintenance

therapy).

Treatment goals

In every patient with periodontitis, a treatment strat-

egy which includes the elimination of the opportun-

istic infection must be defined and followed. This

treatment strategy must also define the clinical out-

come parameters to be reached. Such clinical parame

ters include:

Reduction or resolution of gingivitis (bleeding on

probing; BoP)

Reduction in probing pocket depth (PPD)

Elimination of open furcations in multirooted teeth

Individually satisfactory esthetics and function.

Based on data obtained from longitudinal clinical

studies, which included surgical as well as non-surgi

cal approaches of therapy, the treatment goals may be

further specified:

< 10 %, of sites BoP+

No sites with PPD > 5 mm, but preferably <_ 4 mm

No furcation involvement of degree II or III.

In this context it must also be emphasized that risk

factors for periodontitis that can be controlled must be

addressed as well. The two main risk factors for

chronic periodontitis are

improper plaque control

and

smoking.

Hence the treatment plan must include meas

ures to improve the patient's plaque control

perform

ance. In addition, efforts must be made to

stimulate a

smoker to enroll in smoking cessation

programs.

Initial, cause-related therapy

The objective of this treatment is the removal or con-

trol of the various biofilms.

Additional therapeutic

measures

This includes traditional therapeutic measures such as

periodontal surgery, endodontic therapy, restorative

and prosthetic treatment. The volume of corrective

therapy required and the selection of means for the

restorative and prosthetic therapy can be determined

only when the level of success of the causative therapy