diagnosis abses periodontal

DIAGNOSIS, PROGNOSIS AND

TREATMENT PLAN

Hooman KhorshidiDepartment of PeriodonticsShiraz University of Medical Sciences

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Diagnosis

Diagnosis may be defined as identifying disease from an evaluation of the

history, signs and symptoms, laboratory tests, andprocedures

l) patient interview2) medical consultation as indicated3) clinical periodontal examination4) radiographic examination 5) laboratory tests as needed

Healthy periodontal tissues with minimal inflammation

Systemic diseases with periodontal manifestations

Paroxysmal nocturnal hemoglobinuria with severe leukopenia and associated gingival necrosis


Wegner’s granulomatosis with gingival involvement


Acute monocytic leukemia with thrombocytopenic purpura; gingival enlargement is due to infiltrating leukemic cells, and necrosis

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necrotizing ulcerative gingivitis

Interdental necrosis mesial and distal to the lateral incisor that is characteristic of



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Miller class III gingival recession

Miller class II gingival recession

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Furcation involvement

I-incipient or early suprabony pocket extension into the furcation area with slight loss of bone;II-extension of the pocket into the furcation leaving a portion of the alveolar bone and periodontal ligament intact allowing only partial penetration of the probe into the furcation areaIII-through and through extension of the pocket into the furcation with complete loss of inter-radicular bone without gingival recessionIV-through and through furcationinvasion with gingival recession

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Class IV furcation involvement

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Restorative corrections

Open contactsOverhangsPoor marginsPoor contours

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OverhangsPoor margins

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Dental plaque-induced gingival diseases

1. Gingivitis associated with dental plaque onlya. without other local contributing factorsb. with local contributing factors

2. Gingival diseases modified by systemic factorsa. associated with the endocrine system1) puberty-associated gingivitis2) menstrual cycle-associated gingivitis3) pregnancy-associated

a) gingivitisb) pyogenic granuloma

4) diabetes mellitus-associated gingivitis

b. associated with blood dyscrasias1) leukemia-associated gingivitis2) other

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Classification of periodontal diseases and conditions

Dental plaque-induced gingival diseases

3. Gingival diseases modified by medicationsa. drug-influenced gingival diseases

1) drug-influenced gingival enlargements2) drug-influenced gingivitisa) oral contraceptive-associated gingivitisb) other

4. Gingival diseases modified by malnutritiona. ascorbic acid-deficiency gingivitisb. other

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Non-plaque-induced gingival lesions

1. Gingival diseases of specific bacterial origina. Neisseria gonorrhea-associated lesionsb. Treponema pallidum-associated lesionsc. streptococcal species-associated lesionsd. other

2. Gingival diseases of viral origina. herpesvirus infections

1) primary herpetic gingivostomatitis2) recurrent oral herpes3) varicella-zoster infections

b. other

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3. Gingival diseases of fungal origina. Candida-species infections

1) generalized gingival candidosis

b. linear gingival erythemac. histoplasmosisd. other

4. Gingival lesions of genetic origina. hereditary gingival fibromatosisb. other

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5. Gingival manifestations of systemic conditionsa. mucocutaneous disorders

1) lichen planus2) pemphigoid3) pemphigus vulgaris4) erythema multiforme5) lupus erythematosus6) drug-induced7) other

b. allergic reactions1) dental restorative materials

a) mercuryb) nickelc) acrylicd) other

2) reactions attributable toa) toothpastes/dentifricesb) mouthrinses/mouthwashesc) chewing gum additivesd) foods and additives

3) other

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6. Traumatic lesions (factitious, iatrogenic, accidental)a. chemical injuryb. physical injuryc. thermal injury

7. Foreign body reactions8. Not otherwise specified (NOS)

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Chronic PeriodontitisA. LocalizedB. Generalized

Aggressive PeriodontitisA. LocalizedB. Generalized

Can be further classified on the basis of extent and severity.Extent :

Localized = ≤30% of sites involved Generalized = >30% of sites involved

Severity : Slight = 1 or 2 mm CAL

Moderate = 3 or 4 mm CAL Severe = ≥5 mm CAL

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Periodontitis as a Manifestation of Systemic Diseases

A. Associated with hematological disorders

1. Acquired neutropenia2. Leukemias3. Other

B. Associated with genetic disorders1. Familial and cyclic neutropenia2 Down syndrome3. Leukocyte adhesion deficiency syndromes4. Papillon-Lefèvre syndrome5. Chediak-Higashi syndrome6. Histiocytosis syndromes7. Glycogen storage disease8. Infantile genetic agranulocytosis9. Cohen syndrome10. Ehlers-Danlos syndrome (Types IV and VIII)11. Hypophosphatasia12. Other

C. Not otherwise specified

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Necrotizing Periodontal DiseasesA. Necrotizing ulcerative gingivitis (NUG)B. Necrotizing ulcerative periodontitis (NUP)

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Abscesses of the PeriodontiumA. Gingival abscessB. Periodontal abscessC. Pericoronal abscess

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Periodontitis Associated With Endodontic LesionsA. Combined periodontic-endodontic lesions

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Developmental or Acquired Deformities and Conditions

A. Localized tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis1. Tooth anatomic factors2. Dental restorations/appliances3. Root fractures4. Cervical root resorption and cemental tears

B. Mucogingival deformities and conditions around teeth1. Gingival/soft tissue recession

a. facial or lingual surfacesb. interproximal (papillary)

2. Lack of keratinized gingiva3. Decreased vestibular depth4. Aberrant frenum/muscle position5. Gingival excess

a. pseudopocketb. inconsistent gingival marginc. excessive gingival displayd. gingival enlargement (See I.A.3. and I.B.4.)

6. Abnormal colorC. Mucogingival deformities and conditions on

edentulous ridges1. Vertical and/or horizontal ridge deficiency2. Lack of gingiva/keratinized tissue3. Gingival/soft tissue enlargement4. Aberrant frenum/muscle position5. Decreased vestibular depth6. Abnormal color

D. Occlusal trauma1. Primary occlusal trauma2. Secondary occlusal trauma

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Evaluation of fremitus

Class I½recession that does not extend to the mucogingivaljunction and is not associated with lossof bone or gingival tissue in the interdentalarea; Class II½recession that extends to the mucogingivaljunction and is not associated with loss ofbone or soft tissue in the interdental area;O Class III½recession that extends to or beyond themucogingival junction with loss of bone or softtissue in the interdental area; andO Class IV½recession extending to or beyond themucogingival junction with severe loss of interdentalbone and/or soft tissue and/or severe toothmalposition.

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M O S T D I F F I C U L T D E C I S I O N P R O C E S S

Developing a Prognosis

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Overall clinical factors :AgeDisease severityPlaque controlPatient compliance

AGE

The more rapidly the

problem develops

The younger the

patient with a given

periodontal problem

the poorer the prognosis

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Disease severity

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Systemic, restorative, environmental and local factorPatient compliance and prosthetic possibilityFactors influencing individual tooth prognosis:Plaque and calculus, subgingivalrestoration, caries, non-vital teeth, root resorption

skills and experience

A dentist with limited skills

should refer significant periodontal problems

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medical status of the patient

impaired immune system

poorly controlled diabetes

use of medicines that may induce hyperplasia

heart or blood pressure problems

clotting problems

use of anticoagulants

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Age of patientSkills and experience of dentistMedical status of the patient (general health)

Immunological statusForm of bone lossPossibility of removing etiologic factorPoor nutritional habits, smoking, alcohol abuse, and drug abuseDental conditions (eg, bruxism, malocclusion) Number, position and form of teeth present, Badly involved key abutment teeth, Severe furcationinvolvement, Poor root form, Root proximity

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Age of patientSkills and experience of dentistMedical status of the patient (general health)Immunological statusForm of bone loss

Possibility of removing etiologic factorPoor nutritional habits, smoking, alcohol abuse, and drug abuseDental conditions (eg, bruxism, malocclusion) Number, position and form of teeth present, Badly involved key abutment teeth, Severe furcationinvolvement, Poor root form, Root proximity

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Habits

Poor nutritional habits,

smoking,

alcohol abuse, and

drug abuse • have negative effects on the

prognosis

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psychologic makeup

The ability of the patient to manage stress, follow through with a demanding oral hygiene regimen, and recognize and manage the periodontal problem affect the prognosis

either positively or negatively.

Skill in identifying and assessing these nondental factors is a key to the dentist’s success as a prognostician

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dental factors

occlusal problems such as bruxism or malocclusion must be resolvable, or they will negatively affect the prognosis. Key teeth must be restorable

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Extent of the disease Its rate of progression Status of key abutment teeth Severity of furca involvements Root formRoot proximity

Dental conditions (bruxism, malocclusion)Number, position and form of teeth present,

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An extensive problem with rapid loss of support, especially with few remaining solid teeth or teeth with short or crowded roots or severe furcation involvements, has a poorer prognosis than that for a case in which fewer of these factors are negative.

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Type of prognosis

Hopeless

Questionable

Poor

Fair

Good

Excellent

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TREATMENT PLAN

Hooman KhorshidiDepartment of PeriodonticsShiraz University of Medical Sciences

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Objectives of treatment plan:

Elimination of disease

Restoration of efficient function

Production of satisfactory appearance

Preliminary phase

Non-surgical phase

Surgical phase

Restorative phase

SPT phase

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Emergency

Extraction of hopeless teeth

OHI and patient information

Plaque control and SRP (supra & sub)

Initial occlusion adjustment

Reevaluation after phase І

Surgical phase

Reconstruction (restorative phase)

Maintenance (supportive periodontal

treatment SPT)

Preliminary phase

Pain

Discomfort

Emergencies

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Hopeless teeth

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Non-surgical phase

Phase 1

Plaque control

Cause related

Patient education

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Phase one therapy

Control of plaque

Control of diet

Control of systemic factors

Control of oral malodor and taste

abnormalities

Control of tobacco smoking

CONTROL OF SYSTEMIC FACTORSCONSULT WITH PATIENT’S M.D.

Control of Hemostasis

Control of Bacteremia

Control of Diabetes

Control of Medications

Patient with plaque induced gingivitis

Three weeks following compliance with excellent oral hygiene and plaque control

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Before phase 1

After phase 1

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Removal of pathologic tissue for biopsy

Removal of caries-endodontic therapy

Removal of hopeless teeth

Removal of calculus

Removal of cariesEndodontic therapy

PHASE ONE EVALUATION

Pocket depthPlaque scoreBleeding on probingCariesOcclusal stabilityMobility, fremitusMucosal health statusMucogingival statusSystemic statusRadiographic evaluationOral malodor and tasteEstheticsModification of phase two treatment plans

Surgical phase

Periodontal

Implant

Endodontic

Impacted teeth

…

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Restorative phase

Cast restoration

No conventional filling

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maintenance

SPT (supportive periodontal therapy )

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diagnosis abses periodontal

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