MUDr. Hana Poskerová Ph.D. Dental Clinic St. Anne's Hospital and Faculty of Medicine, Masaryk University Brno Epidemiology and Indexes in Periodontology Perio instruments Examination of oral membrane mucous Epidemiology - study of the health status of the population • WHO will become ill ? WHEN? WHERE? WHY ? Etiological factors • What will we observe? How will we evaluate? • Descriptive epidemiology: description of the condition, formulation of hypotheses • Analytical epidemiology: hypothesis testing, conclusions Epidemiological studies • Description of the natural course of the disease • Occurrence and frequency of diseases in the population • Determined risk / protective factors • Identification of risk groups • Prevention- Therapy- Prognosis Epidemiology of periodontal diseases • Prevalence – total number of cases of the disease in the population at a given time • Incidence – number of new cases within a specified time period • Gingivitis and periodontitis occure almost in 100 % in adults - almost every adult over the age of 40 is affected by periodontitis Epidemiology of periodontal diseases • The need to determine the degree of disease (person, tooth, dental area) • Indicators (indices) - evaluating gingival inflammation, loss of the periodontal tissue • Slow development - long-term observations necessary • Longitudinal study of periodontitis (15 years) 11 % without periodontitis 81 % mild course 8 % destructive course Epidemiology of periodontal diseases • Natural course of the disease • Prevalence of periodontal disease and its degree • Risk factors • Effectiveness of preventive measures • Effectiveness of therapeutic measures • The need for treatment of the population • Multifactorial character of periodontal diseases • Prevalence is increasing improved dental care, longer life expectancy the number of preserved teeth increases Risk factors • Periodontitis - reaction of the organism to dental microbial plaque + host responce + individual factors (total/local) • Dental microbial plaque - Oral hygiene • Age, gender, race, socioeconomic factors, education, income, geographical differences, diet • Local factors • Smoking • Systemic diseases (DM, HIV, genetic syndromes, immune deficiency) Periodontal disease as a risk factor for other diseases • inflammation is not only a local problem of the periodontium, but bacteria and inflammatory mediators enter the systemic circulation • Bacteriemia • Inflammatory mediators 95% of atheromas had bacterial D.N.A from periodontal pathogens https://www.efp.org/news-events/news/oral-health-and-general- health-29938/ Dr. Jiří Sedelmeyer Complex examination in periodontology • Oral hygiene • Dentition • Periodontal tissue • Soft tissues of oral cavity Complex examination in periodontology • Medical history family history – systemic and oral health of parents personal history – diseases and current medications, allergies, tobacco use • Clinical examination - detailed overwiev of periodontal status - detailed examination around each tooth OH, calculus, gingiva, gingival recession, perio pockets, tooth movement, furcation, occlusion • Radiography • Laboratory diagnosis - with a pathogen analysis, gen test • Diagnosis • Prognosis • Method of therapy Complex examination in periodontology Indices in periodontology • Detect pathological changes promptly without detailed evaluation • Not able to produce the diagnosis !!! • Simple, objective, reproducible, cheep, quick and practical, easy interpretable Indices in periodontology • Primarily developed for epidemiologic studies - screening tests • Clinical findings with individual patients help for diagnosis, for patient motivation and education, determination of treatment need, control of therapy results Indices in periodontology • in epidemiologic studies - representative teeth - Ramfjord teeth 16 21 24 / 36 41 44 • with individual patients - the entire dentition Indices in periodontology • Indices provides quantitative and qualitative expresion • quantitative expresion presence – absence of a symptom (yes – no) API • qualitative expresion presence and severity of pathology are expresed by a numerical value (0,1,2,3,4) PBI Indices in periodontology • We examine the indices with periodontological probes • Features - blunt tip (or ball), calibration (various) Indices in periodontology • Plaque Indices PI / API, HYG • Gingival Indices GI / PBI • Periodontal Indices CPITN • Dentition is divided to quadrants / sextants • Ramfjörd teeth / every teeth Hygienic Indices • Recordes plaque accumulation (volume) and distribution of plaque in oral cavity or amount of dental calculus • Evaluate oral hygiene quality and its improvement during the therapy • Examined by probe or staining Plaque index of Silness and Löe • in epidemiologic studies • 0 no plaque • 1 thin film of plaque at the gingival margin, visible only when using an explorer • 2 moderate amount of plaque visible with your own eyes • 3 heavy plaque accumulation Aproximal Plaque Index API • Used with individual patients • Records presence (+) or absence (-) of plaque in interdental spaces as a percentage • 7 interdental spaces in each quadrant • 28 masurement sites in complete dentition • I. and III. quadrant from oral aspect • II. and IV. quadrant from facial aspect • 4 quadrants • I. and III. quadrant from oral aspect • II. and IV. quadrant from facial aspect • 28 masurement sites in complete dentition API Aproximal Plaque Index API • number of locations with plaque / number of evaluated areas  100 (%) • 28/28  100  100% Bad OH • 0/28  100  0% Very good OH • Good motivation ability + + + + – – – – – – + + + + + + + + – – – – – – + + + + 47 46 45 44 43 42 41 31 32 33 34 35 36 37 17 16 15 14 13 12 11 21 22 23 24 25 26 27 Index API number of locations with plaque / number of evaluated areas  100 (%) API  16 / 28  100  56 % Interdental Hygiene Index HYG • reverse • number of locations without plaque / number of evaluated areas  100 (%) • 28/28  100  100% Very good OH • 0/28  100  0% Bad OH – – – – + + + + + + – – – – – – – – + + + + + + – – – – 47 46 45 44 43 42 41 31 32 33 34 35 36 37 17 16 15 14 13 12 11 21 22 23 24 25 26 27 Index HYG number of locations without plaque / number of evaluated areas  100 (%) API  12 / 28  100  44 % Gingival index of Löe and Silness in epidemiologic studies • 0 No inflamation, no discoloration, no bleeding • 1 Mild inflamation, slight colour change, no bleeding • 2 Moderate inflamation, erythema, swelling, bleeding on probing • 3 Severe inflamation, severe erythema and swelling, spontaneous bleeding Papilla Bleeding Index • Used with individual patients • Intensity of bleeding from marginal gingiva upon its soft irritation • Bleeding on probing of the gingival sulcus in the papillary region • Sensitive indicator of the severity of gingival inflamation • Serves for motivating the patients to maintain good OH • 4 quadrants • I. and III. quadrant from oral aspect • II. and IV. quadrant from facial aspect • 28 masurement sites in complete dentition PBI Papilla Bleeding Index • 7 distal papillas/halfpapillas are evaluated • for seven teeth in each quadrant • drying • stimulation of papillas • after 20 sec from stimulation we can record the degree of bleeding Papilla Bleeding Index • Bleeding is provoked by using a periodontal probe under light pressure from the base of papila to its tip along the tooth‘s distal and mesial aspects • Intense of bleeding is scored in four grades Papilla Bleeding Index • distal papillas/halfpapilllas are evaluated in seven teeth in each quadrant • if the 3rd molar is missing, we evaluate the halfpapilla of distal aspect behind the second molar, similarly at the bridge In this case, therefore, no value is missing (it will be missing only if at least 2 adjacent teeth are missing) 7 6 35 12 0 1 point 2 line 3 triangle 4 drop PBI PBI 4 3 2 0 2 • 0 gingiva without bleeding • 1 point bleeding (spot) • 2 stripe bleeding (line) multipoint bleeding • 3 blood fills interdental space (triangle) • 4 spontaneous bleeding, blood flows to adjacent areas (drop) Papilla Bleeding Index • Total value 4  7  (0 - 4) 0 -112 • 4  7  0  0 Very good OH • 4  7  4  112 Bad OH • Index - total value of bleeding papillae / number of examined papilla • Index 0 – 4 1 1 1 1 1 1 7 1 7 7 7 28 123.2.2010 PBI • With the same quality of oral hygiene, it can increase in pregnancy when smoking decreases BOP (Bleeding On Probing) + ─ • bleeding after probing of the periodontal pocket • is a manifestation of inflammation in the depth of the periodontal pocket, a sign of the activity of the disease Community Periodontal Index of Treatment Needs • was developed by WHO in 1978 • universal screenig test for general evaluation of periodontal tissue status • information about pathological changes and about the tratment need • not correct diagnosis CPITN • Gingival bleeding • Presence of dental calculus (iatrogenic irritating factors) • Presence of periodontal pockets Special WHO probe Ball - shaped tip of 0.5 mm Black - coloured zone 3.5 – 5.5 mm CPITN • 0 healthy (?) • 1 bleeding on probing • 2 supra/subgingival calculus, iatrogenic marginal irriration • 3 shallow pockets up to 5.5 mm (3.5 – 5.5) • 4 deeper pockets up to 5.5 mm • CPI 0 - without bleeding - without calculus - without pocket (max. 3.0 mm) CPI 0 CPITN 0 - no bleeding - no calculus - probing up to 3,5 mm (without) so probing can be 0.5 mm /1 mm 2 mm /3 mm • CPI 1 - bleeding of gingiva - without calculus - without pocket (max. 3.0 mm) CPI 1 • CPI 2 - deposits of dental calculus - without pocket (max. 3.0 mm) CPI 2 • CPI 3 perio pockets 3.5 – 5.5 mm CPI 3 • CPI 4 perio pockets of 5.5 mm and more CPI 4 Probing depth 5,5 mm CPITN 4 Probing depth 3,5 mm CPITN 3 CPITN 0,1,2 - probing depth can be 0.5/1/2/3 mm - no pocket CPITN 3 - probing depth can be 4/5 mm - shallow pocket CPITN 4 - probing depth can be 6/7/8.....mm - deep pocket CPITN CPI 4 Bleeding Calculus Pocket probing depth (in mm) CPITN 1 - - 3 0 2 - - 3,5 3 3 - + 3 2 4 - + 3,5 3 5 + + 3 2 6 + + 3,5 3 7 - - 4 3 8 + + 4 3 9 + - 5,5 4 10 - + 5,5 4 11 - - 8 4 12 • TN I (CPI 0,1) - improvement of OH • TN II (CPI 2, CPI 3) - improvement of OH - removing of dental calculus and iatrogenic irritations • TN III (CPI 4) - complete therapy Treatment need CPI TN • 0 healthy • 1 bleeding I. OH • 2 calculus II. OH + CR • 3 pockets up to 5.5 mm • 4 pockets up to 6 mm III. OH + CR + complex perio treatment • For epidemiological studies 17 16 / 11 / 26 27 47 46 / 31 / 36 37 • For individual use Children and adolescents below 19 years 16 / 11 / 26 46 / 31 / 36 Adults - all functional teeth (if only one tooth is in sextant – measured data are evaluated together with the adjacent sextant) 17 - 14 / 13 - 23 / 24 – 27 47 - 44 / 43 - 33 / 34 - 37 • Measurements are made around each tooth • CPITN is taken by sextants (frontal, lateral) • The highest score is recorded for each sextant • Measurements are made around each tooth DV V MV MO O DO 23.2.2010 23.2.2010 3 4 3 3 3 1 0 1 1 1 0 2 2 3 3 3 CPITN 4 1 3 / 4 4 3 3 4 40 0 0 004 1 1 3- -- - CPITN 434/424 Perio pockets • deepnes in mm • BOP (+/-) • pus in pocket Detailed perio examination Intraoral examination in dentistry • Oral hygiene • Dentition • Periodontal tissue • Soft tissues of oral cavity Intraoral examination of oral membrane mucous • Good lightening • Inspection, palpation • Gloves • SYSTEMATICALLY • Comparison of left and right side • Anatomical variations Systematical examination of oral membrane mucous • Lip vermilion • Labial, buccal, alveolar mucosa • Gingiva • Tonque - dorsal surface, lateral borders, undersurface • Floor of the mouth • Palatal mucosa, hard and soft palate, oropharynx • Lip - skin, lip vermilion, angle of the mouth Fordyce‘s granules Cheilitis simplex Herpes labialisFissured lip • Gingiva Linea alba Morsicatio bucarum Fordyce‘s granules • Buccal mucosa • Alveolar • Vestibular mucosa Aphthous ulcers Traumatic ulcer • Labial mucosa Aphthous ulcers Traumatic lesions Allergic reaction • Palatal mucosa, hard and soft palate, oropharynx Rugae palatinae Materia alba Smoker‘s palate Allergic reaction • Tonque – dorsal surface, lateral borders, undersurface Coating tongue Atrophy of the Tonque Fissured (plicated) Tonque Geographic Tonque Black hairy Tonque • Undersurface of the tonque • Floor of the mouth Squamous cell carcinomaRetention cyst • Colour • Surface moisture • Thickness, consistency • Appearance - type, size and configuration of lesions - solitary or multiple lesions • Location, presence of symmetry • Relationship to the other parts of oral cavity Examination of oral membrane mucous Colour of membrane mucous Keratinized Nonkeratinized Colour of membrane mucous • Racial mucosal pigmentation caused by melanin • Smoker‘s melanosis caused by melanin • Amalgam tattoo corrosing process Colour of membrane mucous - White lesions Materia alba Oral lichen planus CandidiasisLeukoplakia Colour of membrane mucous - Red lesions • Inflamation • Atrophy Colour of membrane mucous - Yellow lesions Fordyce‘s granules – sebaceous glands Surface moisture of membrane mucous • Healthy membrane mucous are always wet • Hyposalivation • Hypersalivation Thickness of membrane mucous • thickening – hyperplasia mechanical irritation, drug or hormonal factors, tumors Thickness of membrane mucous • thinnig - atrophy Surface of membrane mucous • Smooth (covered with intact mucosa) • Rough • Ulcerated Smoker‘s palate Papillary hyperplasia Periodontal instrumentarium Instruments for scaling and root planinig Periodontal instrumentarium • Periodontal probes – to locate, measure and mark pockets • Explorers – to locate calculus deposits and caries • Instruments for scaling and root planing (closely curretage) Periodontal probes and explorers Instruments for scaling and root planing • Supragingival scaling instruments • Subgingival scaling and root planing instruments • Ultrasonic and sonic instruments • Cleansing and polishing instruments Instruments for scaling and root planing • Hand instruments - Scalers – sickle s, (chisel s, hoes) - Curettes – universal, Gracey Handle (heavy and thin / light - weighted) Shank (straight - frontal / complex - distal, position of working end in pocket) Working end, cutting edge Supragingival scalers (sickle scalers) Universal curettes Universal curettes Gracey curettes Area specific curettes - Gracey curettes Area specific curettes - Gracey curettes Standard Gracey curretes Rigid curretes Mini curretes Micro curretes After five curretes Mini five curretes Adaptation angulation activation Electronically powered devices • Ultrasonic and sonic instruments developed with the goal making calculus removal easier and faster with less patient discomfort Ultrasonic and sonic instruments Parallel position No pressure With permanent movement Active part only 2 – 4 mm Requires permanent water cooling Infectious spray Comparison of S+U devices and hand instruments • Several mechanisms of action • One mechanism (can remove only what it touches) • The pocket is washing out • Some debris remains in pocket • Less time – more time • Light lateral pressure, relaxed grasp • More presure, hold fast • No sharpening required • Infectious spray • No at patients with cardiostimulator