The Complete Periodontal Examination

Gary C. Armitage

Components of a complete A key component of the history-taking session is periodontal examination determination of the patient's chief complaint. Prior to the examination it is important to know why the A thorough periodontal examination is a critically patient is seeking a periodontal evaluation. With important data-collection activity that is necessary advance knowledge of the chief complaint, the exam- to arrive at a diagnosis and develop a treatment plan. iner can, during the course of the examination, spe- In medically healthy patients with simple and rather ci®cally look for possible explanations or causes of straightforward periodontal conditions, the examina- the patient's problems and concerns. tion can usually be completed in one visit. For medically compromised patients with complex periodontal The initial periodontal examination and dental problems, multiple visits may be needed to complete the data-gathering process. Prior to conducting a periodontal examination it is The purpose of this chapter is to itemize and customary to routinely inspect the extraoral tissues describe the basic components of a complete period- of the head and neck. In addition, examination of all ontal examination and brie¯y review their impor- non-periodontal tissues in the mouth should be per- tance in the overall care of the patient. formed. In other words, a detailed periodontal evaluation is the last component of a thorough oral History and chief complaint examination. Performance of a periodontal examination is a Prior to conducting the hands-on examination, the multi-task activity. While keeping in mind all of the information-gathering process begins with taking information gathered during the history-taking ses- medical and dental histories from the patient. Many sion, the examiner looks for any signs of periodontal practitioners prefer to initiate this process by having disease or other abnormalities. It is, of course, neces- the patient ®ll out a questionnaire. However, ques- sary to have a good idea what healthy periodontal tionnaires are only a starting point, since a discus- tissues look like (Fig. 1). In general, an overall sion with the patient about past and present inspection is made during which changes in color, medical/dental problems nearly always provides shape, and texture of the gingival tissues are additional important information. A valuable aspect assessed. An appraisal of potential etiologic and of this history-taking discussion is that it begins to predisposing factors is continuously being made develop the doctor±patient relationship. Indeed, the during the examination process. Detailed measure- critically important patient-periodontal therapist ments of probing depths and clinical attachment partnership starts during these initial conversations. loss are taken and recorded. Finally, the teeth are In addition, the discussion helps clarify important inspected for occlusal relationships and restorative variables that may affect the periodontal health of needs. the patient. For example, sometimes the only way to obtain a reasonably accurate smoking history is by Recognition of gingival inflammation one-on-one questioning. Procurement of an accurate list of medications that the patient may be taking is One of the very ®rst things to note during a period- facilitated by talking with the patient. ontal examination is the presence or absence of

22 The complete periodontal examination

Fig. 1. Clinical appearance of healthy gingival tissues with female. (c) 40-year-old African-American female with nor- no abnormalities in color, form, contour, or texture. mal gingival pigmentation. (d) 62-year-old Caucasian (a) 14-year-old Caucasian female. (b) 36-year-old Caucasian female. disease. This often can be determined in seconds by healthy site (e.g. such a site is often the adjacent looking for signs of gingival in¯ammation. The four attached gingiva) (Fig. 3). most common signs of gingival in¯ammation that Recognition of gingival swelling or edema requires are routinely observed during a periodontal exami- that the clinician have a very clear mental picture of nation are redness, swelling, bleeding on probing, the shape and texture of healthy gingiva (Fig. 1). and purulent exudate (pus). Healthy gingiva is ®rm and resilient, whereas edema- Gingival redness and swelling usually are seen tous tissue is often enlarged and puffy (Figs 2, 4 and together and occur ®rst at the gingival margin. Without 5). If there is some uncertainty about the presence or treatment the in¯ammation can eventually involve absence of gingival edema, it is sometimes useful to the entire interproximal area (Fig. 2a) and in some gently press the side of a periodontal probe against cases extend into portions of the attached gingiva the tissue for a few seconds and then remove it. At (Fig. 3). Sometimes the redness associated with gin- edematous sites the imprint of the periodontal probe gival in¯ammation can be quite subtle. If one is can often be seen (Fig. 5), whereas at sites without uncertain about the presence of in¯ammation-asso- marked edema no imprint will be observed. Recogni- ciated gingival redness, it is useful to compare the tion of the presence or absence of gingival edema color of the site in question with that of a con®rmed helps the clinician determine if the tissues are

Fig. 2. Mandibular anterior region of a 55-year-old female attachment loss is somewhat less than 7 mm since the with chronic periodontitis. (a) Note that the gingival gingival margin is coronal to the cementoenamel junction papilla between the canine and lateral incisor is red and (not visible). The combination of gingival in¯ammation swollen. (b) Bleeding on gentle probing at the same site. plus a considerable amount of clinical attachment loss Note: the 7 mm probing depth at the site. The clinical indicates that the site has periodontitis (2).

23 Armitage

Fig. 3. Gingival swelling and color change (redness) between the mandibular canine and ®rst premolar affect- Fig. 5. Pitting edema of an edematous interproximal area ing the attached gingiva in a 45-year-old female with in a 65-year-old male with chronic periodontitis. The side chronic periodontitis. The color change can be rapidly of the periodontal probe was gently pressed against the determined by comparing the affected site with the edematous area for a few seconds and then removed. The appearance of the healthy attached gingiva in an adjacent resulting ``pit'' is indicative of the presence of gingival area such as the second premolar and ®rst molar. edema. The tissue is no longer ®rm and resilient. healthy or diseased. In addition, it also serves another absent (Fig. 2b). In¯amed gingival tissues bleed very important purpose ± anticipating the response when gently probed because of minute ulcerations to treatment. Gingival edema and the accompanying in the pocket epithelium and the fragility of the redness often disappears shortly after scaling and underlying vasculature. At the initial examination root planing. Therefore, by noting that the tissues the percentage of sites that exhibit bleeding on prob- are edematous during the examination, the clinician ing prior to treatment is a clinically useful piece of can predict the likely response to therapy. information since it provides a full-mouth pretreat- It should be remembered that not all areas of gin- ment assessment of the extent of gingival in¯amma- gival redness and swelling are due to periodontal tion. For example, if 70% of the sites exhibit bleeding diseases. Endodontic infections sometimes drain on probing prior to treatment, a decrease to 20% of through the ori®ce of a periodontal pocket thereby the sites after initial scaling and root planing and oral mimicking a periodontal abscess (Fig. 6). Elsewhere hygiene instructions is encouraging to both the this volume discusses in detail the diagnosis of endo- patient and periodontist by indicating that progress dontic-periodontal lesions (10). has been made. In other words, knowledge of this Bleeding on probing is a somewhat objective sign improvement reassures the patient and periodontist of gingival in¯ammation; it is either present or

Fig. 6. Gingival swelling of endodontic origin on the inter- Fig. 4. Swollen gingival papilla in a 17-year-old male. In proximal gingiva between the molar and second bicuspid. this case the center of the swollen papilla has developed a The molar was undergoing endodontic treatment for a ``dimple'' due to loss of tissue tone. necrotic pulp.

24 The complete periodontal examination

Fig. 7. Mandibular anterior region of a 55-year-old female overlying the central incisor can be seen. (b) Same area with chronic periodontitis (same patient as shown in Fig. 2). after digital pressure has been applied to the gingiva of the (a) Note the in¯amed area between the lateral and central central incisor. Note the purulent exudate at the distal incisor. Color change including all of the attached gingiva gingival margin of the central incisor. that their joint efforts to control the periodontal are associated with rapid and extensive destruction infection are working. of bone and surrounding tissues. The diagnosis of Although purulent exudate (pus) can occasionally acute periodontal lesions is discussed in detail else- be found at sites with gingivitis, it is most often where in this volume (3). detected at sites with chronic periodontitis. Pus is a neutrophil-rich exudate that is found in about 3±5% Detection of departures from normal of sites with untreated periodontitis (1). Without ques- anatomy, shape, and form tion, its presence signi®es that the site is in¯amed and infected. The best way to detect the presence of During the examination, notations should be made pus is to gently apply digital pressure to the overlying of any deviations from normal periodontal anatomy gingiva in a coronal direction (Fig. 7). Conventional such as alterations in contour, aberrant frenal attach- wisdom suggests that the presence of pus is an unfa- ments, and minimal amounts or lack of keratinized vorable sign. However, available data suggest that gingiva. These items are of particular importance if suppuration is not a good stand-alone predictor of they interfere with the patient's ability to perform the progression of chronic periodontitis (1). This state- oral hygiene procedures. ment only applies to the relatively small amounts of Altered gingival contours can be the result of a pus produced at sites with chronic periodontitis. The wide range of factors. They become clinically impor- importance of copious amounts of pus often seen at tant if they create esthetic problems, make plaque sites with periodontal abscesses is a different situa- control dif®cult, or interfere with function. For exam- tion (Fig. 8). Highly purulent periodontal abscesses ple, gingival enlargement is a well-known side effect

Fig. 8. Highly purulent periodontal abscess on a mandib- from a large accumulation of pus. (b) A massive amount of ular central incisor in a 38-year-old female. (a) The entire pus was released immediately after an incision was made vestibule in the lower anterior region was markedly swollen to drain the abscess. (Courtesy of Dr. Gilbert V. Oliver.)

25 Armitage

Fig. 9. A 35-year-old female with gingival enlargement Fig. 11. Bilateral large mandibular tori in a 45-year-old associated with the ingestion of phenytoin to help control female that interfered with oral hygiene procedures. cerebral seizures. The gingival enlargement created esthetic problems for the patient and was her chief complaint. of certain medications (e.g. phenytoin, nifedipine, cyclosporine) (Fig. 9). Sometimes the enlargement is due to unusual anatomic variations (Fig. 10). Occa- sionally, mandibular tori can be come so large that they interfere with chewing or impede access for plaque control procedures (Fig. 11). Little needs to be said about these alterations in contour because they are clinically obvious and are often associated with the patient's chief complaint. However, men- tion should be made of subtle changes in gingival contour that are sometimes overlooked, but have clinical importance. In some patients with longstanding chronic periodontitis, the gingiva becomes ®rm and enlarged in reaction to the chronic in¯ammation (Fig. 12±14). Sometimes such tissues are referred to as ``®brotic.'' In contrast to gingival enlargement due to tissue edema, ®brotic enlargements will not disappear after scaling and root planing. This Fig. 10. Localized enlargement of the palatal gingiva in knowledge is important since it helps the clinician the molar region in a medically healthy 32-year-old anticipate what tissue changes will occur after non- female. The enlargement was bilateral and was considered to be an unusual anatomic variation. The enlarged gingiva surgical therapy. The best way to con®rm that the was the focus of the patient's chief complaint. tissue is ®brotic is to gently press on the gingiva with

Fig. 12. A 49-year-old male with chronic periodontitis. (a) Lingual view of the same teeth shown in A. The The altered contours and enlargement of the interproximal interproximal gingiva with increased redness was highly gingival papillae were due to the longstanding inflamma- edematous, thereby increasing the likelihood of consider- tion. The papillae were firm and ``fibrotic'' and the contours able shrinkage after nonsurgical therapy. did not appreciably change after nonsurgical therapy. (b)

26 The complete periodontal examination

Fig. 15. An unusual case of a 24-year-old female who lacked keratinized gingiva in most areas of her mouth. The atypically thin gingiva was at high risk for developing recession from both plaque-induced inflammation and damage during toothbrushing. Both causes of recession were etiologic factors in this patient. Cases similar to this have been reported by Moskow & Baden (8).

Fig. 13. Fibrotic gingiva in the maxillary anterior region in a 52-year-old male. The gingival contours will not change prone to toothbrush-induced damage followed by after nonsurgical therapy. recession (Fig. 15). Aberrant frenal attachments are anatomic features the side of the periodontal probe. Unlike the reaction that should be noted if they contribute to a clinical of edematous tissue to this procedure, no imprint of problem. This item is discussed in detail elsewhere in the probe will be left behind. this volume (6). However, the most common situa- During the examination, notations should be made tion in which they become a problem is when they about narrow bands, or the complete absence, of interfere with oral hygiene or other self-care proce- keratinized gingiva. This item is discussed in detail dures. For most patients it is uncomfortable to brush elsewhere in this volume (6). However, the main non-keratinized tissues such as frena and alveolar clinical importance of an adequate zone of kerati- mucosa. Therefore, if the frenal attachments are nized gingiva is that it is often necessary for the located close to the gingival margin, patients tend patient to comfortably perform oral hygiene proce- to avoid cleaning these areas and plaque-induced dures. The gingiva overlying teeth with narrow zones periodontal disease develops (Fig. 16). In some of keratinized gingiva is often thin and is thereby instances a frenum is located near the gingival margin of a tooth in an area with little or no keratinized gingiva (Fig. 17). Such a combination should be considered to increase the risk for the future development of periodontal problems at the site and should most certainly be noted at the time of the initial examination. In other cases a very prominent frenum may be attached at the mucogingival junction where there is an adequate band of keratinized healthy gingiva coronal to the attachment (Fig. 18). Under these circumstances the risk of developing a periodontal problem is unlikely because the patient can adequately clean the site.

Fig. 14. Gingiva with altered contours in the same patient Assessment of etiologic and predisposing shown in Fig. 13 Some of the enlargement was due to factors edematous changes and some had already become fibrotic. In such cases, nonsurgical therapy will only During the course of a periodontal examination the result in partial resolution of the gingival enlargement. clinician should begin to develop an idea of what

27 Armitage

Fig. 18. Attachment of a prominent frenum at the muco- Fig. 16. Multiple frena attached to positions on the gingiva gingival junction in an area where there is enough that make oral hygiene difficult and uncomfortable. Note keratinized gingiva to permit good oral hygiene. the heavy calculus deposits, an indication that the patient does not (or cannot) effectively clean the areas. and will not be repeated here. However, when present they should be noticed and recorded. As the etiologic and predisposing factors are present. As the information is being collected it is important to keep examination is being performed the clinician should in mind what is known about potential risk factors develop an impression of what modi®able factors for chronic periodontitis such as cigarette smoking, might be responsible for, or increase the risk of, per- poor compliance, aging, psychological stress, and iodontal infections. Where are the heaviest deposits genetic susceptibility. These and other risk factors of plaque and calculus? Are there local contributing are discussed in detail elsewhere in this volume (9). factors that might increase the risk for periodontal infections? Conceptually, one is looking for etiologic Assessment of periodontal damage items or predisposing factors that can be modi®ed by therapeutic interventions. Tooth-related factors such Assessments of periodontal damage are a mandatory as close roots, palatal-gingival grooves, furcation component of a complete periodontal examination. anatomy, cervical enamel projections, overhangs Measurements taken with calibrated periodontal on dental restorations, and other local contributing probes are the main way in which damage to factors are all discussed elsewhere in this volume (6) the periodontium is assessed. Such measurements include probing depth, clinical attachment loss, and gingival recession. Probing depth and clinical attachment loss measurements are routinely recorded at six sites around each tooth (i.e. mesiobuccal, buccal, distobuccal, mesiolingual, lingual, and distolingual). During the course of periodontal probing the instru- ment is stepped around the entire circumference of the tooth and the deepest reading nearest each of the six sites listed above is recorded. In other words, an attempt is made to probe every portion of the gingival crevice or pocket around each tooth. This routine of thoroughly probing all locations is usually followed since it is often impossible to tell from the super®cial appearance of the gingiva if sites will have deepened probing depths and loss of attachment Fig. 17. Attachment of a frenum between two mandibular (Fig. 19). In addition to the above assessments, central incisors near the gingival margins of both teeth. radiographs are a necessary adjunct to a thorough Note the lack of keratinized gingiva in the area. Both teeth periodontal examination. A detailed discussion of have an increased risk of developing plaque-induced imaging methods (including radiography) can be periodontal problems if oral hygiene cannot comfortably be performed at the sites. The situation should be found elsewhere in this volume and will not be recorded at the initial periodontal examination. repeated here (7).

28 The complete periodontal examination

Fig. 19. Gingiva in a 38-year-old female that superficially of 8 mm (b). The patient had received scaling and root looks healthy (a). Insertion of a periodontal probe on the planing by the referring dentist approximately 6 weeks mesiobuccal side of the first molar reveals a probing depth prior to taking these photographs.

Probing depth is the distance from the gingival Some clinicians elect not to take clinical attachment margin to the base of the probeable crevice. Probing loss measurements at the initial examination but wait depth measurements are important because they until active treatment has been completed. The main give a good approximation of the principal habitat reasons for this are that many changes occur in clin- of periodontal pathogens (i.e. periodontal pockets). ical attachment loss as a result of therapy and the Knowledge of the depth, extent, and location of measurements are easier to obtain once supragingi- pockets gives the clinician a good idea where therapy val and subgingival calculus has been removed. might be directed. Indeed, probing depth reduction Nevertheless, prior to placing patients in the main- is often one of the important goals of many forms of tenance phase of therapy, clinical attachment loss periodontal therapy. However, probing depth mea- readings should be taken since these measurements surements do not necessarily give the best approx- serve as a baseline from which future determinations imation of the amount of periodontal damage since of additional attachment loss are judged. the reference point from which the measurements Gingival recession is the distance from the CEJ to are taken (i.e. the gingival margin) may ¯uctuate in the gingival margin (GM). Recession is often of major apical or coronal directions. For example, at one concern to patients since it is a readily visible man- examination the probing depth at a given site might ifestation of periodontal damage and can cause be 4 mm, but at a later date gingival in¯ammation esthetic problems when in occurs around anterior can cause gingival swelling that results in migration teeth. Indeed, many patients have a chief complaint of the gingival margin 2 mm coronally. The probing of ``receding gums.'' Therefore, at the initial exam- depth at this later date would be 6 mm (i.e. 4 mm ination it is important to record the amount and 2 mm) even though no additional periodontal location of gingival recession. damage had occurred. Conversely, if at a later date Damage from periodontal disease often involves the 2 mm of additional attachment loss occurred and the furcation areas of multirooted teeth. The severity of gingival margin receded 2 mm apically, the probing furcation involvement is an important factor in deve- depth would still be 4 mm. In other words, the gin- loping a treatment plan for affected sites. Therefore, gival margin is not a ®xed landmark from which valid during a complete periodontal examination the loca- assessments of additional damage can be made. tion and severity of furcation involvements should be Clinical attachment loss is the distance from the recorded. Onecommon classi®cationsystem for furca- cementoenamel junction (CEJ) to the base of the tion involvement includes: Class I (beginning), Class II probeable crevice. If the CEJ landmark is missing (cul-de-sac), and Class III (through-and-through). A because it has been destroyed by dental caries or has detailed discussion of the classi®cation, diagnosis, been removed by placement of a dental restoration, and importance of furcation involvements can be another ®xed reference point can be used to measure found elsewhere in this volume (6). attachment loss. Such landmarks might include the The ®nal assessment of periodontal damage that apical margin of a restoration or the incisal edge of a should be recorded during a complete periodontal tooth. When attachment loss measurements are taken examination is abnormal tooth mobility. Although from a ®xed landmark other than the CEJ they are this symptom may have several causes other than called relative attachment loss measurements. Clinical periodontal infections (5), loss of alveolar bone from attachment loss or relative attachment loss measure- periodontitis is a major cause of abnormal tooth ments are the best way to assess the presence or mobility. In addition, it is sometimes part of the absence of additional periodontal damage. patient's chief complaint (e.g. ``My teeth are loose.'').

29 Armitage

The diagnosis and overall importance of tooth mobi- are collected virtually at the same time. In this step lity are discussed in elsewhere in this volume (4). the examiner calls out a probing depth reading. Then a second number is called out that represents the CEJ Inspection of the teeth to GM distance. Finally, if the site exhibits bleeding on probing, the examiner says ``bleeding,'' and the Although the primary focus of a periodontal exam- recorder places a ``dot'' ( ) in the box where the ination is the periodontium, the teeth also need to be clinical attachment loss measurement will eventually carefully inspected for dental caries, restorative probe inserted. As will be seen in a moment, the clinical blems (6), and occlusal discrepancies (4). Tooth- attachment loss reading is a derived number obtained related problems have considerable importance in by adding the CEJ to GM distance to the probing the overall periodontal treatment plan. depth measurement. For beginners the CEJ to GM reading can be a source of confusion. There is usually no problem in under- Recording the findings standing how to measure gingival recession (i.e. the CEJ to GM distance when the gingival margin is apical There are many types and styles of periodontal charts to the CEJ). The CEJ to GM measurement can be easily to choose from. Selection of one charting system over obtained since both of the reference points (i.e. CEJ another is entirely up to the preferences of the indi- and GM) are in full view. In addition, there is usually vidual practitioner. Most acceptable charting sys- not a problem in understanding that the clinical tems are simple, easy to ®ll out and read, and attachment loss can be obtained by adding the prob- contain all of the relevant information collected during depth to the amount of gingival recession. For ing the periodontal examination. An example of such example, if there is a 4 mm probing depth and 2 mm a chart is shown in Fig. 20. The periodontal chart is a of gingival recession, the clinical attachment loss at permanent record that can be used in assisting the the site is 6 mm (i.e. 4 mm 2 mm). The problem practitioner to arrive at a diagnosis and prognosis, occurs when the gingival margin is coronal to the CEJ develop a treatment plan, and longitudinally evalu- (i.e. when there is no gingival recession). In this case, ate the response to therapy. only one of the reference points (i.e. GM) is in full To ef®ciently ®ll out a periodontal chart requires view of the examiner. To determine the CEJ to GM the help of a dental assistant who serves as a recorder measurement the examiner must feel for the CEJ of the examination ®ndings. As the clinician calls out with the tip of the periodontal probe and estimate the measurements or assessments they are recorded how far coronally the GM is from the CEJ. If the GM is in the chart. The chart shown in Fig. 20 has places for at the CEJ, the number called out by the examiner assessments of probing depth, the presence or would be ``zero.'' If the GM is 1 mm coronal to the absence of plaque, clinical attachment loss, the pre- CEJ, the number called out by the examiner would be sence or absence of bleeding on probing, and the ``minus one.'' If the GM is 2 mm coronal to the CEJ, distance from the CEJ to the gingival margin the number called out by the examiner would be (CEJ ± GM). As mentioned above, in the section on ``minus two.'' In other words, when the GM is cor- ``Assessments of periodontal damage'' measure- onal to the GM, the CEJ to GM measurement is ments or assessments at six sites around each tooth recorded as a negative number. For example, if there are usually recorded. is a 4 mm probing depth and the CEJ to GM distance Some examiners prefer to record, as the very ®rst is ± 2 mm, the calculated clinical attachment loss at step, the presence or absence of plaque on each the site would be 2 mm (i.e. 4 mm ± 2 mm). tooth and surface. In the chart shown in Fig. 20, if The chart in Fig. 20 has been ®lled out using the supragingival plaque is present a ``dot'' ( ) is placed examination ®ndings from a patient with generalized in the box where the probing depth measurements severe chronic periodontitis. In addition to the will be inserted. The second step is to measure the probing depth, clinical attachment loss, and other probing depth, CEJ to GM distance, and the presence assessments discussed above, commonly used or absence of BOP. These three pieces of information symbols have been placed to re¯ect the extent of

Fig. 20. Example of a periodontal chart showing some of the clinical information collected during examination of a 36- year-old male with generalized chronic periodontitis. CAL clinical attachment loss; BOP bleeding on probing; PD probing depth; Plaque visible plaque (plaque index score 2 using Silness & LoÈe system (11)); CEJ ± GM distance from cementoenamel junction to gingival margin.

30 The complete periodontal examination

31 Armitage furcation involvement (L incipient; D cul-de-sac; treatment evaluation examination is to determine if ~ through-and-through) and mobility (I slight, the administered therapy was successful in arresting II moderate, III severe). Many other symbols to the patient's disease. The examination also provides signify a variety of clinical ®ndings are used by prac- baseline or benchmark data to which all clinical data titioners. There is no standard set of symbols that are collected at subsequent examinations can be com- universally accepted by the majority of clinicians. pared. The important thing is that the symbols be consis- In a busy practice, as the number of patients on tently used and are understood by others who might recall/maintenance programs increases, it is often be called upon to read the chart (e.g. a referring dif®cult to rapidly assimilate, review, and compare all dentist or colleague). of the information collected from multiple examina- Although the chart shown in Fig. 20 provides site- tions. Indeed, the sheer amount of clinical data speci®c details of the collected assessments, it also becomes overwhelming after the patient has been provides the raw data from which some valuable on a maintenance program for several years. If one full-mouth information can be calculated. In this patient has 28 remaining teeth, each examination will patient, full-mouth summary data include: sites with generate 168 data points (i.e. six per tooth) for each probing depth 5mm 53.7%, clinical attachment assessment made or measurement taken. Since the loss 5mm 64.2%, bleeding on probing 71.6%, periodontal chart shown in Fig. 20 has places for ®ve and visible supragingival plaque 66.7%. This infor- clinical variables (i.e. clinical attachment loss, prob- mation is useful in a number of ways and it has ing depth, bleeding on probing, plaque, CEJ ± GM dis- immediate applications in communicating with the tance), each exam could generate 840 pieces of data patient. For example, it is very easy to point out to the (i.e. 5 Â 168). If the patient is placed on a 3-month patient that one of the reasons they have periodontal recall program and the examination is repeated at disease is that two-thirds of their tooth surfaces have every visit, 3,360 data points will be generated in visible plaque. Over 70% of the sites bleed, which is a 1 year, 16,800 in 5 years and 33,600 in 10 years. Ways sign of the infection and well over half of the sites to overcome or deal with this potential burden include: have deep pockets with signi®cant damage. After utilizing computers during data entry and subse- successful treatment, marked reductions in the per- quent analysis, emphasizing or focusing on clinical centages of sites with plaque and bleeding on prob- attachment loss measurements, and reducing the ing will always occur. Simply showing the patient the number of examinations from 4 per year to 1 per year. improved percentages can be gratifying and Computerized systems including software are encouraging to both patient and therapist. The needed to cope with the large amount of data col- important point being raised here is that data collected during multiple examinations. Computers can lected during a periodontal examination are not just automatically track changes in each of the assess- for the therapist's eyes. If presented in an under- ments and bring them to the attention of the clin- standable way, patients can also bene®t from seeing ician. Since clinical attachment loss measurements the clinical data. are the best way to track the progression of period- In addition to the data traditionally recorded on ontal disease, it makes sense to emphasize this the periodontal chart, the initial examination usually assessment in the longitudinal evaluation of period- generates other important information that may be ontal status. Finally, for most patients it is probably valuable in the subsequent development and execu- suf®cient to conduct full examinations or data col- tion of a treatment plan. Such items are usually lection procedures once per year instead of quarterly. entered, in detail, in the ``Progress Notes'' section If this last option is chosen, the clinician should of the patient's chart. selectively and closely monitor high-risk or fragile sites at frequent intervals. The best option, of course, is to examine as frequently as is practical and enlist Follow-up (maintenance-phase) the aid of computer technology to assist in tracking examinations any changes in periodontal status.

After completion of active periodontal therapy, prior to placing the patient on a maintenance program, the References examination should be repeated. The information to be collected is the same as that obtained during 1. Armitage GC. Periodontal diseases: diagnosis. Ann Period- the initial examination. A key purpose of this post- ontol 1996: 1: 37±215

32 The complete periodontal examination

2. Armitage GC. Clinical evaluation of periodontal diseases. 7. Mol A. Imaging methods in periodontology. Periodontol Periodontol 2000 1995: 7: 39±53 2000 2004: 34: 34±48. 3. Corbet EF. Diagnosis of acute periodontal lesions. Period- 8. Moskow BS, Baden E. Unusual gingival characteristics having a ontol 2000 2004: 34: 204±216. familial tendency: a case report. Periodontics 1967: 5: 259±264 4. Hallmon WW, Harrel SK. Occlusal analysis, diagnosis and 9. Ronderos M, Ryder MI. Risk assessment in clinical practice. management in the practice of periodontics. Periodontol Periodontol 2000 2004: 34: 120±135. 2000 2004: 34: 151±164. 10. Rotstein I, Simon JHS. Diagnosis, prognosis and decision- 5. Jordan RCK. Diagnosis of periodontal manifestations of sys- making in the treatment of combined periodontal-endo- temic diseases. Periodontol 2000 2004: 34: 217±229 dontic lesions. Periodontol 2000 2004: 34: 165±203. 6. Matthews DC, Tabesh M. Detection of localized tooth- 11. Silness J, LoÈe H. Periodontal disease in pregnancy. Part II. related factors that predispose to periodontal infections. Correlation between oral hygiene and periodontal condi- Periodontol 2000 2004: 34: 136±150. tion. Acta Odontol Scand 1964: 22: 121±135