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Profile in Oral Health Trisha E. O’Hehir, RDH, MS, Hygienetown Editorial Director

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by Trisha O’Hehir, RDH, MS, Hygienetown Editorial Director

Introduction

Diagnosis is recognizing the signs and symptoms of disease – being able to distinguish health from disease. Clinically healthy gingival tissues are pale pink in color, have thin marginal areas, stippled surface texture (looking like orange peel), and on probing there is resilience that feels like rubber and no bleeding.

Ideally, all the patients in your practice are diagnosed as periodontally healthy, but based on the number of "bloody prophies" occurring every day in this country, that isn't true. The first step in periodontal diagnosis is simply identifying those people who are healthy, according to the definition above, and those who are not. Classification comes later after making the distinction between health and disease and when you ask more questions: is it chronic or aggressive; mild, moderate or severe; associated with a systemic disease; involving abscesses; a necrotizing infection; associated with an endodontic lesion; involved with developmental or acquired factors; and is the patient a smoker? Answers to these questions come after you've made the distinction between health and disease.

The first step is deciding who isn't healthy. When you diagnose "periodontal disease," distinguish between these three distinct conditions: gingivitis, chronic periodontitis and aggressive periodontitis. Based on the criteria used to define "periodontal disease," estimates are as high as 90 percent of the population when gingivitis is included along with chronic and aggressive periodontitis. Chronic periodontitis estimates vary depending on whether the study called for full mouth probing or partial mouth probing. Another variable in prevalence studies is the angle of the probe. If the researchers insist on holding the probe parallel to the long axis of the tooth for all measurements, they will miss the mid-interproximal surfaces of the posterior teeth and grossly underestimate the extent of disease. Partial mouth probing instead of full mouth probing is also a reason for missing disease. According to a press release from the AAP dated September 21, 2010, new research suggests that current estimates of the prevalence of chronic periodontitis might underestimate the actual prevalence by 50 percent. When separating out gingivitis and chronic periodontitis, researchers estimate the prevalence of severe periodontitis to be between five to 15 percent and aggressive periodontitis to be one percent of the population.

It's easy to distinguish between health and bone loss, but diagnosing gingivitis poses a problem. The procedure codes created by the ADA and used by insurance companies contain no procedure codes to treat gingivitis, so it's off the radar. Right now the codes include one procedure code to treat periodontally healthy patients (prophylaxis) and several procedure codes to treat chronic or aggressive periodontitis (SRP and surgery). Since there are no codes for treating gingivitis, both health and gingivitis are often lumped together. The problem here is that the vast majority of the population currently has gingivitis but is being led to believe they are periodontally healthy. Without procedure codes to treat gingivitis, those patients are either treated as healthy or as having chronic periodontitis. Both are inaccurate diagnoses.

There are several clinical indices including probing depth, bleeding, suppuration, recession, mobility and furcation involvement to be considered when making a periodontal diagnosis. Laboratory tests are now available to provide information about bacteria involved and genetic susceptibility, leading to more accurate treatment decisions and information sharing with patients. Adding to this are the many risk factors that need to be taken into consideration when making a diagnosis and prognosis. Here's a brief overview of the clinical signs and laboratory test available to assist in making a periodontal diagnosis.

Bleeding
To make a diagnosis of gingivitis, look first at the tissues for color change or texture change due to swelling. Bleeding is our most objective clinical measure of gingivitis. However, sometimes probing depth suggests periodontal disease, but the clinician doesn't see bleeding on the examination, but instrumentation elicits bleeding. It might be the probing technique that missed inflamed tissue and bleeding. If the probe is simply inserted into the pocket, barely reaching the clinical attachment, bleeding might not be seen. To detect bleeding, the entire subgingival area should be examined, not just one probe point.

According to commonly used bleeding indices, the probe is either inserted just apical to the gingival margin or to the depth of the sulcus or pocket. The Gingival Index first described in 1963 by Drs. Silness and Löe inserts the probe just apical to the gingival margin and the tissue is gently stroked laterally with the edge of the probe to determine bleeding. Bleeding upon probing requires the probe to be inserted to the epithelial attachment and then walked around the entire sulcus from one point to the next, covering six points circumferentially around the tooth. This method should cover the entire epithelial attachment around the tooth. Bleeding might be immediate or become visible within seconds.

A third bleeding index used by clinicians and researchers can also be used by patients as a self-test for gingivitis. It's the Eastman Interdental Bleeding Index or EIBI. A triangular-shaped wooden pick is inserted between the teeth from all facial surfaces until it fits tightly. It is then moved in and out four times in a rubbing action, depressing the interdental papilla at least one millimeter and exerting pressure on the papilla. This index was shown to be a more accurate representation of inflammatory tissue infiltrate than bleeding upon probing. Using a triangular wooden stick exerts the same amount of pressure each time, dictated by the size of the interproximal space. The force exerted when using a periodontal probe can and does vary considerably between clinicians, leading to variations in bleeding scores.

Bleeding is not an accurate indicator of gingivitis in smokers. Nicotine causes vasocontriction, reducing bleeding scores, but this does not mean that smokers are healthy. There are other factors that need to be considered, especially probing depth, attachment loss and bone levels.

Clinical Implication: Examine the entire subgingival attachment area and sulcular or pocket epithelial wall to determine bleeding. Remember, the sulcular/pocket wall is an open wound that needs to be examined in its entirety. Bleeding might be reduced in smokers, so look for other factors including probing depths, attachment loss and bone levels.

Probing Depth Scores
Treatment decisions are often based primarily on probing depth scores, when many other factors should be considered as well. The first should be bleeding, which provides information about the level of current inflammation. Interproximal surfaces are at greatest risk for periodontal disease due to the lack of keratinaziation of epithelium in the col area and the protection these areas provide subgingival bacterial biofilm. When possible, follow Dr. Howard Farran's probing suggestion, first probe brushing surfaces (facial and lingual) and then probe flossing surfaces (interproximal). Changing the pattern of probing provides an opportunity to educate patients about the connection between their oral hygiene activities and the current level of health or disease in their mouth. However, when using automated probing devices or computerized recording of probing scores, the pattern of probing will be the traditional round-the-tooth approach. These methods allow patients to hear the range of probing scores, but not which specific surfaces they represent.

Probing technique focuses on three aspects to ensure proper probe placement. Start with the probe parallel with the long axis of the tooth, keeping the probe tip in constant contact with the tooth surface. The probe tip remains in contact with the tooth surface as it follows the tooth contour moving subgingivally to the base of the sulcus or pocket. Second, aim the probe tip to the mid-point of interproximal surfaces to gain access to the area right under the contact. Avoid probing only line angles with a parallel probe placement, thus missing the mid-interproximal point. Third, keep the side of the probe against the contact as the tip moves interproximally to create a reproducible reference point to compare future measurements.

Clinical Implication: Probing depths provide information about the extent of tissue breakdown when disease is present. Probing circumferentially around each tooth provides the most accurate picture of periodontal health or disease.

Recession
Recession is generally measured on facial surfaces, sometimes on lingual surfaces and rarely on interproximal surfaces. Some charts only allow for two recession measurements per tooth, one facial and one lingual. Measuring and recording recession on all six probing points around a tooth provides the information necessary to calculate clinical attachment loss. This will provide a more accurate picture of the periodontal condition.

Recession is measured from the CEJ to the gingival margin. Sometimes the CEJ is obscured by restorations. Finding a reference point to begin the measurement will provide a reproducible measurement.

Clinical Implication: Measure recession at six points around each tooth, to provide information to calculate clinical attachment levels.

Clinical Attachment Level
Adding the recession score and the probing depth score together provides the clinical attachment score. This number is indicative of the bone loss already experienced by the patient. This number provides an accurate view of both soft tissue and bone destruction from periodontal disease.

Clinical Implication: A 5mm probing depth might not seem too serious, but when 3mm of recession is added, for a clinical attachment level of 8mm, the situation is much more serious.

Mobility
Class I and II mobility represent the extent of lateral tooth motion. Class III denotes both lateral and occlusal tooth movement. Measurements are made with two instrument handles, exerting force in one direction and then the other, noticing the distance the tooth moves. Placing one instrument handle tip on the occlusal surface or incisal edge of a tooth and pushing will determine if there is occlusal movement into and out of the socket. Measuring mobility with fingers or with one instrument handle and a finger will provide inaccurate data, as finger tissue compression might be interpreted as movement, thus confusing the measure of actual tooth movement.

Clinical Implication: Mobility indicates more than a bacterial infection as occlusal discrepancies and interferences might be exacerbating the situation.

Bone Loss
Bone loss is evaluated using both conventional and digital radiographs, but does not capture bone loss visible to the eye until 30 to 50 percent of mineral content is lost. Differences in mineral content between spongiform bone and compact bone are responsible for this, according to Dr. Per Axelsson in his textbook Diagnosis and Risk Predictors of Periodontal Disease. Probing depth might be considerably deeper in posterior interproximal areas, with no evidence yet of radiographic bone loss. It might be several months until the mineral loss is detected on radiographs. Subtraction radiography is the best way to determine differences in bone levels between radiographs.

Clinical Implication: Bone loss provides a picture of disease history. However, there might be more bone lost than is visible in radiographs.

Furcaton Involvement
Furcation probes provide a marked curved probe to assess furcations more accurately than traditional straight probes. Furcation measurements are made horizontally rather than vertically. Furcation involvement is categorized as:
  • Class I – bone loss not exceeding one-third the width of the tooth
  • Class II – bone loss exceeding one-third of the tooth width, but not through-and-through
  • Class III – through-and-through destruction of supporting bone in the furcation
Clinical Implication: Teeth with furcation involvement, especially Class III, provide a significant challenge to treat because access to the "roof " of the furcation is difficult.

Salivary Testing
Saliva contains information about the bacteria associated with periodontal disease. Gingival crevicular fluid mixes with saliva to provide immediate information about what's happening inside the sulcus or periodontal pocket. Saliva also contains genetic information to determine if a patient is genetically susceptible to periodontitis.

Two periodontal salivary tests are available from the OralDNA Labs that measure bacterial DNA and genetic susceptibility to periodontitis. The patient swishes with sterile saline, expectorates into a funneled tube, and the tube is then shipped to the laboratory for analysis. When the laboratory report is available, the clinician is notified electronically of the results.

The bacterial tests check for DNA evidence of 13 periodontal pathogens. The Periodontal Susceptibility Test (PST) identifies genetic differences responsible for an exaggerated immune response of increased cytokine production. This genetic difference might lead to more serious periodontal disease. Clinical Implication: Salivary tests provide an additional laboratory option for gathering valuable diagnostic information.

Future Diagnosis
Chairside, point-of-contact testing or over-the-counter home saliva tests will eventually become available for oral as well as systemic diseases. Salivary diagnosis is now possible, but available only to researchers for oral cancer, breast cancer, salivary gland diseases and biomarkers for periodontal disease.

The future will bring the NanoSensor, a handheld, automated, oral fluid sensor for rapid detection of multiple salivary proteins. Screening chips are designed with information to test immediately against the saliva sample. The screening chip for each disease or condition is the size of a credit card and is inserted into a handheld machine along with the saliva sample. It won't be long before dentists and dental hygienists have greater involvement in the identification and monitoring of oral and systemic diseases.

Clinical Implication: In the not-too-distant future, clinicians will provide point of contact salivary testing for oral health conditions as well as systemic diseases, and consumers will buy over-the-counter saliva tests to measure and monitor their periodontal health.

Conclusion
The best clinical diagnostic tool we have for gingivitis and periodontitis today is bleeding on probing, with the absence of bleeding being the more accurate predictor of health. Not all bleeding on probing leads to bone loss, but all bone loss is preceded by gingivitis. Make the distinction between health, gingivitis and periodontitis with an accurate diagnosis using the clinical and laboratory diagnostics we have available today. This is essential to providing the appropriate treatment and preventing future disease progression. The future will bring less invasive, chairside saliva tests to revolutionize periodontal diagnosis.
Dentaltown Magazine
September 2025
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