A screening method for periodontal disease - jdao … management of the patient or refer the patient to an appropriate specialist. PD screening should be repeated before orthodontic

DOI: 10.1051/odfen/2012404 J Dentofacial Anom Orthod 2013;16:104� RODF / EDP Sciences

1

Conflicts of interest declared by the author: NONEArticle received: 01-2012.

Accepted for publication: 09-2012.

A screening method forperiodontal disease

Solenn HOURDIN, Dominique GLEZ,

Gilles GAGNOT, Olivier SOREL, Sylvie JEANNE

SUMMARY

The objective of this article is to offer a simplified and reasonable approachfor periodontal disease screening that should be a mandatory part of each andevery oral examination. The main purpose of this examination is to answerthe question of whether or not there are any infection sites that requireperiodontal management. This assessment has three parts: the initial patientinterview (medical history), the clinical oral examination and the radiologicalexamination. Using a periodontal probe, the dentist should place a highpriority on performing PD screening and it should be done systematically androutinely during every consultation.Orthodontists and dentists are both licensed to perform this examination.After this examination, the practitioner can make a diagnosis, initiateperiodontal management of the patient or refer the patient to an appropriatespecialist.PD screening should be repeated before orthodontic treatment or before anyfunctional rehabilitation in order to maintain periodontal stability.

KEY WORDS

Screening,

Periodontal disease,

Multi-disciplinary,

Probing measurement.

Periodontal disease is an infectiouspathology characterized by an inflamma-tion. Among the progressive forms of thisdisease, the pathognomonic or hallmark

sign is the periodontal pocket: an increasein the depth of gingival sulcus greaterthan 3 mm with apical displacement ofthe gingival attachment. The insidious

Address for correspondence:

S. HOURDIN,Faculte de chirurgie dentaireDepartement de Parodontologie,Departement d’Orthodontie,Universite de Rennes,2, av. du Pr Leon Bernard (Bat 15)35043 Rennes [email protected] available at http://www.jdao-journal.org or http://dx.doi.org/10.1051/odfen/2012404

http://www.jdao-journal.org

http://dx.doi.org/10.1051/odfen/2012404

development of periodontal infectionsand their delayed diagnosis explainsthe high prevalence of severe peri-odontitis1,6-8.

These considerations more thanjustify performing a periodontalexamination each and every timea patient comes in for a dentalconsultation.

Unfortunately, the traditional meth-od used for diagnosis, that is still rec-ommended today, is thorough,complete and tedious4,5. From thestart, in an exacting manner, withtooth by tooth inspection, the diagno-sis seeks to identify various clinicalfactors, to locate lost attachmentsand any tooth mobility, to measurethe depth of the periodontal pockets,the gingival recessions, the height ofthe keratinized gingiva2,3. . .Collectingall this data is impractical in the con-text of total dentistry or orthodontics.

Besides, the new methods for diag-nosis, based on the use of electronicprobes, biological dosage for differentmarkers of periodontal disease oreven techniques using advancedimaging, still do not make it feasibleto draw clinical conclusions that arepertinent18,19. Finally, periodontalscreening is never mentioned, eventhough it informs future therapychoices.

Periodontal screening should be-come a standard practice since it isintended to identify patients at riskand to eliminate reservoirs of bacteriaat an early stage.

The objective of this article is tooffer a simplified and reasonableapproach for periodontal diseasescreening that should be a routinepart of each and every oralexamination.

1 – SCREENING METHOD

The main purpose of this periodon-tal examination is to answer thequestion of whether or not there areany sites of infection that requireperiodontal management.

This assessment has three parts:the initial patient interview (medicalhistory), the clinical oral examinationand the radiological examination.

1 – 1 – Medical history

The patient interview makes it pos-sible to:– target the risk factors for periodon-

tal diseases11,16;

– determine the risk for PD as itrelates to the general health of thepatient: complications such asinfections, hemorrhaging or scar-ring before the initiation of treat-ment. The examiner should payspecial attention to the capacity ofthe immune responses of thepatient;

– make patients become more awareof PD by questioning them aboutthe symptoms of their chronicdisease12.A medical questionnaire specifically

designed for PD screening willoptimize time spent interviewing thepatient.

SOLENN HOURDIN, DOMINIQUE GLEZ, GILLES GAGNOT, OLIVIER SOREL, SYLVIE JEANNE

2 Hourdin S, Glez D, Gagnot G, Sorel O, Jeanne S. A screening method for periodontal disease

1 – 2 – Clinical examination

It is based on a binary method. Atthis point, the practitioner does notfocus on the intensity of the clinicalsigns but whether or not there aresigns of periodontal disease. It is di-vided into four stages: inspection,gingival palpation, dental palpationand probing.

• Inspection

The practitioner is looking for areasof erythema and edema mainly in thepapillae (Figs. 1 and 2), as well asthe presence of dental plaque.

• Gingival palpation

Oral gingival palpation from apical tocoronal on all the teeth makes it possi-ble to express the exudate containedin the periodontal pocket and/or to re-veal the presence of blood and pus,markers of activity10 (Figs. 3 and 4).

• Dental palpation

Dental palpation makes it possibleto evaluate the stages of tooth mobil-

ity that are markers for the severityof bone lysis15.

It is important to emphasize thatthe absence of the signs and symp-toms previously described does notallow the examiner to exclude thepresence of periodontal pockets (pro-gressive periodontal disease) (Fig. 5).

Figure 1Gingivitis.

Figure 2Inflammed areas characteristic of active periodontitis.

Figure 3Digital pressure from the apical to coronal areasmakes it possible to reveal the presence of pus.

A SCREENING METHOD FOR PERIODONTAL DISEASE

Rev Orthop Dento Faciale 2013;16:104. 3

• Probing

At this stage, ‘‘detection probing’’is the only examination that makes itpossible to validate the presence ofperiodontal pockets.

Unlike conventional periodontalcharting13,14, ,periodontal detectionprobing is performed starting with thevery first office visit using the sameCP15 Hu-Friedy� probe. But, the fo-cus is not on the probe values or evenon the location of the infected sites.Working from a binary mode andusing the depth scale measurements,the practitioner can determinewhether or not there are pockets.Three stages can present: < 4 mm,between 4 and 6 mm, > 6 mm.

During the examination, the practi-tioner methodically probes the sixpoints of each tooth with the CP15Hu-Friedy� probe. The absence ofperiodontal infection is validated bythe total absence of pockets.

Conversely, as soon as the exami-nation shows evidence that there areperiodontal pockets on at least fourteeth, the examiner stops the prob-ing because the test results are assu-redly positive for the presence ofperiodontal disease.

Figures 4a and 4bClinical images of periodontitis before (a) and afterpalpation (b).

Figures 5a and 5ba: image of progressive periodontitis: absence

of inflammatory signs;b: radiological image: demonstrating bone loss.

The clinical oral picture is deceptive sincethere are few signs of inflammation and thegingiva have a very coronary border.



1 – 3 – Radiological examination

It demonstrates the bone loss butdoes not detect whether or not thereare reservoirs of periodontalinfection9.

The radiological examination com-pletes the detection probing and al-lows the practitioner to make a fact-based diagnosis. A digital panoramic

examination is recommended at thisstage17. It offers the advantage ofbeing simple and quick. Since it isreproducible, it presents an overalland multidisciplinary view of the oralcavity. If need be, this examinationcan be completed with periapicalfilms.

2 – CLINICAL SYNTHESIS

The data gathered thus far pro-vides a solid basis for rating the pa-tient according to the followingcategories: no periodontal disease,stabilized periodontal disease, peri-

odontal disease with progressive gin-givitis or marginal/moderateperiodontitis, and finally, severe pro-gressive periodontitis (Tab. I).

Figure 7For a = 4 mm probing, the biofilm can no longer betreated by improved patient hygiene because now,there is a reservoir of periodontal infection.

Figure 6Detecting pockets while probing is the pathogno-monic sign of periodontal disease.

Figure 8The CP15 Hu-Friedy� probe.



• The absence of periodontal dis-

ease is characterized by the ab-sence of inflammatory signs, ofpockets greater that 4 mm andbone loss. Therefore, the practi-tioner does not need to considertreatment. However, if dental pla-que is present, the orthodontistshould proceed with prophylacticcleaning (Fig. 10).

• Stabilized periodontal disease ischaracterized by the absence ofinflammatory signs, the absenceof pockets = 4 mm, the presenceof bone loss. The practitionershould set up supportive periodon-tal treatment (Fig. 11).

• Progressive periodontal disease

with gingivitis or marginal/mod-

erate periodontitis is character-i z e d b y t h e p r e s e n c e o finflammatory signs and/or probing

values of 4 to 5 mm, with little or nobone loss (Fig. 12). For this cate-gory, the prognosis for preservingthe teeth is favorable but periodon-tal cleaning must be performed.

• Progressive periodontal disease

with severe periodontitis is char-acterized by the presence of possi-ble signs of inflammation, byprobing values 4 � 6 mm and bysevere bone loss. For this category,since the prognosis for preservingthe teeth is uncertain, a periodontalcleaning should be performed assoon as possible (Fig. 13).If the initial periodontal diagnosis

turns out to be positive (last threecategories), it will be followed laterby a consultation so that the practi-tioner can explain the disease, dis-cuss the treatment procedures anddemonstrate techniques for plaque

Figures 9a to 9cPeriodontal disease is a disease of site(s). Therefore, the examiner must probe 3 points on each face of the tooth.On the 23 shown here, the infectious reservoir is only found on the distal surface.



control that are individualized for thepatient.

Immediately following this peri-odontal consultation, the practitionerhas to manage the psychological as-pects of this disease because itschronic nature can lull the patient into

becoming less vigilant about control-ling plaque.

In the case of progressive peri-odontal diseases (last two catego-ries), the patient must receive athorough periodontal diagnosis in or-der to plan appropriate treatment.

Inflammatory

SignsPockets Radiological

bone loss

Therapeutic

consequences

Healthy

periodontium- - - No periodontal

treatment

Stabilized periodontal

disease- - + Supportive periodontal

treatment

Progressive

periodontal

disease or

marginal/moderate

periodontitis

+/- 4 to 5 mm +/-

Depth probing diagnosis and

periodontal restoration with

favorable prognosis

Progressive

Periodontal

Disease with

Severe periodontitis

+/- � 6 mm +

Depth probing diagnosis and

periodontal restoration with

uncertain prognosis

Table IThis collection of data (inflammatory signs, depth of pockets and bone loss) helps the examiner categorizepatients into four types and each calls for a different treatment.

Figures 10a and 10bPatient with no periodontal disease: clinical view (a) and radiographic view (b).



Figures 12a and 12bPatient presenting progressive periodontal disease with marginal periodontitis whilemouth breathing: clinical view (a) and radiographic view (b).

Figures 13a and 13bPatient presenting progressive periodontal disease with severe periodontitis: clinical view (a) and radiographicview (b).

Figures 11a and 11bPatient presenting stabilized periodontal disease: clinical view (a) and radiographic view (b).



3 – CONCLUSION

The method for detection of peri-odontal disease that is described inthis article incorporates all the classicstages of any diagnostic process:interview, clinical oral examinationfollowed by a radiological examina-tion.

The detection probing with a dentalprobe must be done routinely andsystematically and given the highestpriority in order to avoid delayedtreatment that can occur if PD goesunnoticed by the patient and theunenlightened dentist.

Periodontal screening cannot showin an overly detailed manner, the

stage of periodontal disease for everytooth but using the binary approach,it does make it possible to assertwhether or not there is an infectionand to quickly begin treatment.

Both orthodontists and dentists arelicensed to perform this examination.It makes it possible to make a diag-nosis, to begin periodontal manage-ment of the patient or to refer thepatient to an appropriate specialist.

The examination should be re-peated before any orthodontic treat-ment or prior to any functionalreconstruction in order to maintainperiodontal stability.

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A screening method for periodontal disease - jdao … management of the patient or refer the patient to an appropriate specialist. PD screening should be repeated before orthodontic