Diagnosing Gum Disease
Before any periodontal intervention, a diagnosis must be made. To reach a diagnosis, the patient’s dental and medical histories must be taken, a clinical examination must be performed, and diagnostic full mouth x-rays (radiographs) must be reviewed. Today, CBCT imaging is also a common diagnostic imaging modality for periodontal disease assessment and treatment planning. These steps are generally accomplished during the initial consultation appointment, although a second consultation appointment may be needed, particularly when additional information must be obtained.
Dental / Medical Histories
For decades we have known that a prime indicator for future periodontal breakdown is a past history of periodontal disease. By taking a dental history and evaluating previous x-rays, we have a better understanding about the rate of disease progression, and can determine what must be done to prevent further breakdown. In the last decade, periodontists have also begun to understand that periodontal disease is a result of bacteria interacting with the patient’s defense systems. How the patient’s body responds to the bacterial (plaque) assault depends on the “host” resistance. Some people are fortunate, and have minor periodontal disease even with poor oral hygiene. For others, the same amount of bacteria may cause advanced periodontal disease and bone loss.
In other words, certain patients are very susceptible to periodontal disease, and these patients must be particularly diligent with their oral hygiene and maintenance to reduce the bacteria challenge. By taking a complete medical history we can determine if the patient has certain risk factors and may modify treatment accordingly. Below are the most significant general health considerations that may affect periodontal disease susceptibility.
Smoking– A host risk factor that CAN be altered, and one that GREATLY increases the risk of disease.
Diabetes– Increases the risk of disease if not well controlled.
Stress– Long-term stress may adversely alter the way we fight periodontal disease.
Hormones– Increases in gingival inflammation is seen with increased levels of estrogen.
Medications– Dilantin and several common heart medications may cause medication-induced gum overgrowth.
Severe Osteopenia/Osteoporosis– May result in more jawbone loss or more tooth loss, particularly in post-menopausal women.
Family History/Genetics– A portion of the population is genetically more susceptible to periodontal disease.
The periodontal examination gives us a complete picture of the periodontal condition of your oral health. This information is needed before an accurate diagnosis can be made. The oral exam is supplemented with information gained from full mouth radiographs and/or CBCT imaging. Sometimes, bacterial samples are obtained using salivary DNA analysis and evaluated to determine the presence of an aggressive disease pattern. In some instances, adjunctive use of antibiotics in combination with periodontal treatments is recommended.
A major focus of the exam is to determine how much bone loss (extent and location) has occurred. When healthy, there is generally a 2-3 millimeter space (sulcus) between the tooth and the gum. This space deepens as bacterial plaque causes bone deterioration, and penetrates down the side of the tooth. This deepened space is called a “periodontal pocket”.
Each tooth is measured (probed) (See What is Gum Disease?) at six places, surrounding the tooth, to determine the pocket depth. Normally anesthesia is not needed for this charting, which gives the dentist a blueprint of periodontal changes.
- Gum recession– The amount of recession added to the pocket depth determines total attachment (bone) loss.
- Furcations– Bone loss into the furcation of a tooth compromises the prognosis.
- Amount of attached gingiva– Without adequate attached gingival (hard stong gum tissue that is bound down to bone, not cheek like moveable gum tissue), gum recession will likely occur.
- Occlusion (bite)– Excessive forces on teeth may accelerate bone loss.
- Tooth mobility (looseness)– Generally indicates inadequate bone support or a bite problem.
- Patient oral hygiene– Poor brushing and flossing will greatly compromise the long-term result.
Dental Radiographs (x-rays)
A full mouth dental x-ray series is mandatory to accurately evaluate and diagnose your oral health. Today, this is accomplished using digital technology and the radiation exposure is a fraction of the historic plain film xray exposure. They help determine the amount and location of bone loss, the size and shape of the roots, the amount of root still embedded in the bone, the relationship of the teeth to each other, whether the nerve in a tooth has died, the location of the sinus and mandibular nerve when placing implants, and oral pathologies, among other things. We are not able to treat a patient unless we have adequate x-rays that are of diagnostic quality. On occasion this may necessitate that we secure our own x-rays for you. The exception is gingival grafting, which normally does not require x-rays. In addition, some cases benefit from CBCT imaging due to the highly advanced diagnostic quality and expanded diagnostic, prognostic and treatment planning benefits inherent in 3D analysis.
There are a number of different types of dental x-rays, each with a specific purpose, but for periodontal treatment a full series of periapical films is generally required. Below is a list of the commonly taken x-ray views:.
Full Mouth Periapicals– 18-21 detailed views of the teeth and surrounding bone, necessary for an accurate periodontal examination.
Panograph– A single screening film showing an overview of the upper and lower jaws, sinus, temporomandibular joint, and other anatomic features.
Vertical Bitewings– Four to seven detailed views of the teeth that can show both decay and bone levels when severe bone loss has not occurred.
Digital x-rays– Any x-ray that is stored digitally, on a computer. Generally available in periapical and bitewings only.
CBCT Scan– Cone Beam Computed Tomography used for highly accurate and sophisticated 3D analysis.
Once the clinical data is gathered and correlated with the x-ray findings, your periodontist is able to organize and systematically evaluate the results to make a diagnosis. This is critical, for while there may be various approaches to treat a problem, there can be only one correct diagnosis.. Once the diagnosis is determined, prognosis can be established and various treatment options can be formulated for your personalized situation. With this information the periodontist and the patient can determine which treatment plan to follow.