SUMMARY

Diagnosis of Periodontal Disease

Principles of Diagnosis

• Sensitivity – refers to the ability of a test or observation to detect the disease, wherever it is present.
• Specificity – refers to the ability of a test or observation to clearly differentiate one disease from another.
• Predictive value – refers to the probability of a test result.

Pocket Depth and Level of Attachment

• Pocket depth is the distance between the gingival margin to the base of the pocket (or coronal end of functional epithelium).
• If the gingival margin is on anatomic coronal, then level of attachment = pocket depth – distance from CEJ to the gingival margin.
• If gingival margin coincides with CEJ, then level of attachment = pocket depth.
• If gingival margin is apical to CEJ, then level of attachment = pocket depth + distance from CEJ to gingival margin.
• Pocket depth is less important than level of attachment because it is not necessarily selected to bone loss.
• A tooth with deep pockets may have little bone loss, while a tooth with shallow pocket may have severe bone loss.
• Prognosis is considered as poor if the base of the pocket (level of attachment) is close to root apex.

Radiographic & Clinical Diagnosis

• Radiography does not reveal the presence of pocket or soft tissue lesion or morphology of bone destruction.
• Transgingival probing and visual examination by surgical exposure are the definitive ways for knowing bone morphology.
• Definitive diagnosis of furcation involvement, poor and periodontal abscess is made by clinical examination only.
• CBCT provides better diagnostic and quantitative information on periodontal bone levels in 3D.
• CBCT provides similar horizontal and vertical dimensions of the defects as provided by the direct probing measurement.

How to Record the BPE

1. The dentition is divided into 6 sextants and the highest score for each sextant is recorded:
   
   Upper right (17 to 14)
   Lower right (47 to 44)
   
   Upper anterior (13 to 23)
   Lower anterior (43 to 33)
   
   Upper left (24 to 27)
   Lower left (34 to 37)
2. All teeth in each sextant are examined (with the exception of 3rd molars unless 1st and/or 2nd molars are missing).
3. For a sextant to qualify for recording, it must contain at least 2 teeth.
4. A World Health Organisation (WHO) BPE probe is used. This has a ‘ball end’ 0.5 mm in diameter and a black band from 3.5 mm to 5.5 mm. Light probing force should be used (20–25 grams).
5. The probe should be ‘walked around’ the teeth in each sextant. All sites should be examined to ensure that the highest score in the sextant is recorded before moving on to the next sextant. If a code 4 is identified in a sextant, continue to examine all sites in the sextant. This will help to gain a fuller understanding of the periodontal condition and will make sure that furcation involvements are not missed.

Code	Guidance	Special Investigations	Periodontal Reassessment
0	No need for periodontal treatment	None indicated	Repeat BPE at next check-up appointment
1	Oral hygiene instruction (OHI)	Plaque and bleeding charts	Repeat BPE at next check-up appointment
2	As for code 1, plus removal of plaque retentive factors, including all supra and subgingival calculus	Plaque and bleeding charts	Repeat BPE at next check-up appointment
3	As for code 2 and OHI, root surface debridement (RSD) if required	Plaque and bleeding charts Radiographs should be considered (in order to establish if there is attachment loss)	Periodontal charting of sextants scoring 3, after initial therapy
4	OHI, RSD. Assess the need for more complex treatment; referral to a specialist may be indicated	Plaque and bleeding charts Radiographs should be taken	Full periodontal charting before and after treatment
*	Treat according to BPE code (0–4). Assess the need for more complex treatment; referral to a specialist may be indicated	Plaque and bleeding charts Radiographs should be considered	Full periodontal charting before and after treatment

Radiographic Assessment in Periodontology

When to Take Radiographs?

• Radiographs aid diagnosis, prognosis, treatment planning, and monitoring stability of periodontal health.
• They help assess alveolar bone loss, tooth morphology, and detect other pathologies like periapical lesions, furcation, and caries.
• Each radiograph must be:
  • Clinically justified
  • High in quality
  • Beneficial to the patient

Initial Presentation

• Radiographs may be part of special investigations following BPE.
• Radiographs are generally indicated for BPE codes 3, 4, and * to assess bone loss.
• Definitive imaging choice can be postponed until a detailed periodontal chart is obtained.

Supportive Periodontal Therapy

• Used to monitor bone changes, especially in furcation involvement or aggressive disease.
• Radiographs should be taken based on clinical need, not routine schedule.
• Radiographic bone changes are slow, so timing must balance monitoring and radiation exposure.
• No evidence-based guideline exists for exact frequency of radiographs in periodontal care.

Types of Radiographs

Horizontal Bitewings

• Primarily used for caries detection but can indicate early bone loss.
• Useful for detecting subgingival calculus and overhanging restorations.
• Proper positioning shows undistorted bone levels relative to CEJ.

Vertical Bitewings

• Provide better view of bone levels between opposing arches.
• May be harder to position, especially in shallow palates.
• Use periapicals if root/apical assessment is required.

Periapicals

• Gold standard for periodontal assessment.
• Use long-cone paralleling technique and beam aiming device for accuracy.
• Visualizes full root length and CEJ relation to bone.
• Useful in:
  • Assessing prognosis
  • Furcation involvement
  • Endodontic complications

Dental Panoramic Tomographs (DPTs)

• Not recommended for routine screening due to low yield and higher radiation.
• Consider in complex dental cases with multiple concerns.

Periapical vs. Panoramic Radiographs

• Periapicals: More accurate and detailed for periodontal defects.
• Panoramics: Faster, more comfortable, less detailed, can require supplemental periapicals.
• Anterior image distortion in panoramics may reduce accuracy.
• Use rectangular collimation for periapicals and field-size collimation for DPTs to reduce radiation.

Radiographic Periodontal Assessment

• Documentation of findings in clinical notes is a medico-legal requirement.
• Assess and record:
  • Bone loss percentage (if apex is visible)
  • Type of bone loss: horizontal vs. angular
  • Furcation defects
  • Subgingival calculus
  • Other findings: perio-endo lesions, widened PDL, abnormal roots, overhanging restorations

Prognostic Use of Radiographs

• Deep angular defects (>3mm): limited pocket reduction with non-surgical therapy expected.
• Multiple angular defects/furcation involvement: consider complex care or referral.

Prognosis in Periodontal Disease

Definition

Classification of Prognosis

Excellent Prognosis

• No bone loss
• Excellent gingival condition
• Good patient cooperation
• No systemic/environmental factors

Good Prognosis

• Adequate remaining bone support
• Control of etiologic factors
• Maintainable dentition
• Good patient cooperation
• No or controlled systemic/environmental factors

Fair Prognosis

• Less than adequate bone support
• Some tooth mobility
• Grade I furcation involvement
• Acceptable maintenance and patient cooperation
• Limited systemic/environmental factors

Poor Prognosis

• Moderate to advanced bone loss
• Tooth mobility
• Grade I or II furcation involvement
• Doubtful patient cooperation
• Difficult to maintain areas
• Presence of systemic/environmental factors

Questionable Prognosis

• Advanced bone loss
• Grade II or III furcation involvement
• Tooth mobility, inaccessible areas
• Systemic/environmental factors

Hopeless Prognosis

• Advanced bone loss
• Non-maintainable areas
• Extraction indicated
• Presence of uncontrolled systemic factors

Factors Determining Prognosis

Factor Type	Examples
Overall Clinical Factors	1. Patient age 2. Disease severity 3. Plaque control 4. Patient compliance
Systemic/Environmental Factors	1. Smoking 2. Systemic diseases 3. Genetic factors 4. Stress
Local Factors	1. Plaque/calculus 2. Subgingival restoration 3. Anatomic factors: — Short, tapered roots — Enamel projections — Enamel pearls — Bifurcation ridges — Root concavities — Furcation involvement — Developmental grooves
Prosthetic/Restorative Factors	1. Abutment selection 2. Caries 3. Non-vital teeth 4. Root resorption

Phases of Periodontal Therapy

Phase	Description
Preliminary Phase	Treatment of emergencies: Dental or periapical Periodontal Other Extraction of hopeless teeth and provisional replacement if needed (may be postponed to a more convenient time).
Non-surgical Therapy (Phase I)	Plaque control and Patient education Diet control (especially in rampant caries) Removal of calculus and root planing Correction of restorative and prosthetic irritational factors Excavation of caries and temporary/final restoration Antimicrobial therapy (local/systemic) Occlusal therapy Minor orthodontic movement Provides splint and prosthesis
Evaluation of Response to Non-Surgical Phase	Rechecking: Pocket depth and gingival inflammation Plaque and calculus, caries
Surgical Phase (Phase II)	Periodontal therapy including placement of implants Endodontic therapy
Restorative Phase (Phase III)	Final restoration Fixed and removable prosthodontic appliances Evaluation of response to restorative procedures Periodontal examination
Maintenance Phase (Phase IV)	Periodic rechecking: Plaque and calculus Gingival condition (pockets, inflammation) Occlusion; tooth mobility Other pathologic changes