Diagnosis in periodontology
- Introduction:
After the clinical examination is completed, the practitioner is ready to identify the disease that caused the patient to consult him, this is called making a diagnosis. The next step will be to assess the chances of treatment success by establishing an accurate prognosis and proposing a complete treatment plan.
Making the diagnosis is therefore the result of exploiting the data from the clinical examination. These data can be used both in determining the etiology and in assessing the severity and type of the disease according to the classifications of periodontal diseases.
II- Definitions:
-Diagnosis: comes from the Greek word “diagnôsis”, which means both discernment and decision. It is the part of the medical act that aims to determine the nature of the disease observed. It is based on a classification that has gained unanimity among those involved in periodontology, as is the case with Armitage or the new classification proposed by the Chicago World Workshop in 2017.
-Etiological diagnosis: this is the part of the diagnosis that aims to find the various causes of periodontal disease. It determines the nature and role of the different possible etiologies and cites them as local, general or constitutional etiological factors.
-Differential diagnosis: consists of eliminating clinical entities whose signs and symptoms are similar to those of the positive diagnosis; we eliminate diseases that are more or less similar by looking for clinical, radiological, or even bacteriological differences.
-Positive diagnosis: it is the determination of a disease after the collection of all its symptoms and signs, it is presented as the deduction of the clinical examination and the study of the various complementary examinations. The observation report written at the end of the clinical examination is compared with the descriptions proposed by the classification of periodontal diseases.
II- the diagnostic approach and clinical examination:
1-The anamnesis:
The defenses of women’s periodontal tissues are exacerbated by various hormonal variations during their life, in addition women are more likely to keep appointments than men.
Profession: There are certain professions that have repercussions on the state of the periodontium.
General background:
- Detect general conditions that could modify the reaction of the periodontium to local factors;
- General problems that require a change in the treatment to be carried out;
- Look for certain general conditions that present an immediate or mediate contraindication to any surgical procedure;
- Determine the presence of certain general diseases responsible for periodontal disease;
- To detect contagious diseases likely to endanger the health of the practitioner and his staff.
The reason for consultation and history of the disease; pain, bleeding, swelling and bad breath allows the practitioner to trace the history of the disease.
The history of the disease is an investigation which should allow the practitioner to locate the start of the disease and its slow or progressive development.
2-Exorbital examination:
The coloring of the skin: it informs us of possible anemia, fatigue, dermatological problems, or even scars;
The absence or presence of stomion informs us about the type of breathing.
Examination of the masticatory muscles and their insertion as well as examination of the ATMs guides the diagnosis towards the involvement or not of anomalies of the masticatory system in the pathogenesis of periodontitis.
The search for adenopathies directs the diagnosis towards infectious or tumoral pathologies
3-The intraoral examination:
Oral hygiene: The correlation between local factors and the severity of existing inflammation should be sought.
– Salivary flow: decreased salivary secretion or hyposialia: the cause must be sought (chronic diseases, lesions of the salivary glands) which can cause dry mouth, which is a factor promoting the accumulation of bacterial plaque, the appearance of erythema and cracks.
-increased salivary secretion or salivation caused by the use of certain medications (such as bromides, iodides), or the sign of certain stomatitis, of a GUNA
-The state of the mucous membranes: Any changes within the oral mucosa should be noted, looking for an inflammatory, infectious or tumoral focus.
-Insertion of frenums and flanges: Pathological insertion of frenums and flanges constitutes an important etiological factor in the retention of bacterial plaque, the appearance of periodontal recessions, or persistence.
4-Periodontal examination:
-Gingival examination:
Guides the diagnosis by specifying the correlation between the severity of the inflammation with etiological factors such as the quantity of plaque and retention factors as well as with the anatomical conditions of the gingiva.
-Probing the gingivodental sulcus:
It allows to evaluate: the depth of the pocket, and the loss of attachment as well as the severity of the bleeding on probing . This information gives an idea of the severity of the lesions caused by periodontal disease and determines whether we are dealing with a case of periodontitis or gingivitis.
Probing the gingival sulcus also helps diagnose possible furcation involvement.
5-Dental examination:
Cracks and abrasions can be a sign of occlusal trauma (during bruxism or other parafunction)
Pathological mobility of a tooth can lead to different diagnoses
- more or less advanced periodontitis
- primary or secondary occlusal trauma
- different types of abscesses, cysts or tumors
- endo-periodontal lesions
6-Occlusal examination and function examination
The existence of occlusal overloads directs the diagnosis towards the functional pathogenesis of periodontitis
A particularity to note in the case of mouth breathing, this will have an impact on the anterior zone with the appearance of edema and hyperplasia while the posterior sectors are less or not at all affected by gingivitis.
7-Radiagnosis of periodontal disease:
Allows to confirm and reinforce the results of the clinical examination, which is chronologically first, and those of the radiographic examination. According to Prichard, the radio serves as a monitor for the clinical examination: it can confirm it or suggest doing a new one in certain areas
Other diagnoses can be established following other complementary examinations carried out if necessary; microbiological diagnosis, immune diagnosis and molecular diagnosis.
IV-The etiological diagnosis:
An essential part of the examination is to determine the etiological factors of periodontal diseases, this not only serves to achieve a positive diagnosis and prognosis, but also to highlight the problems that must be eliminated in order for the disease to be treated. The main causes of periodontal disease were described in 1936 by Weski in the form of a triad.
This diagnosis allows the practitioner to properly organize the etiological therapy of periodontal disease.
V-The positive diagnosis:
According to Charon, the positive diagnosis will be more precise and easier to develop if we ask ourselves 04 questions:
1-What is the activity status?:
Signs that may indicate the progress of periodontal disease:
-Suppuration:
May indicate an acute (abscesses) or chronic (chronic periodontitis) condition
-Halitosis:
-Bleeding:
– bone lysis and the condition of the lamina dura or compact bone of the alveolar crest:
Rams et al, 1994 were able to show that the presence of the lamina dura is often associated with periodontal lesions at rest while its absence can be interpreted as a sign of activity.
-Mobility-migration:
In the presence of clinical, radiological and microbiological signs of attachment loss of infectious origin, the sudden worsening of mobility and/or the appearance of migration may very well represent a sign of infectious activity.
2-What is the stage of progress?: disease in its early stages or advanced?
It is defined by the depth of attachment loss.
3-What is the nature of the flora?
The answer to this question allows to distinguish a disease caused by specific or polymorphic plaque to be confronted also with the results of the history of the disease
4-What type of disease is it?
To answer this question, the practitioner must rely on one of the many classifications recognized by the scientific community, in particular that of Armitage (1999) and the Chicago workshop of 2017.
VI-Differential diagnosis:
It aims to confirm the positive diagnosis and consists of eliminating clinical entities whose signs and symptoms are so similar as to mislead the practitioner.
It is done by looking for clinical, radiological, or even bacteriological differences between the different diseases that can affect the periodontium in our patient.
For example:
-GUNA done with ulcerative gingivitis (leukemia patients) will be eliminated by questioning, and a blood test.
-Hypertrophic gingivitis depending on the etiology, we will eliminate that of local, hormonal, respiratory etiology.
– generalized aggressive periodontitis will occur with localized aggressive periodontitis and this by the extent of the disease
-Conclusion :
The very numerous different clinical forms of periodontal diseases share many clinical signs that are also numerous and varied, this will constitute one more reason to respect the systematic execution of the stages of the clinical examination reinforced if necessary by additional examinations.
The practitioner will thus be able to use the information collected to make the correct diagnosis and propose a well-founded treatment plan.
Diagnosis in periodontology
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