Paraclinical examination.

Radiographic examination (OPG,

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od_practitioners_guide_2016.pdf?v=3
 When to take radiographs?
 Radiographs can be used to aid diagnosis
and help determine the likely prognosis of
specific teeth when taken together with a
comprehensive clinical examination and
patient history

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od_practitioners_guide_2016.pdf?v=3
  By permitting assessment of the
morphology of the affected teeth and the
pattern and degree of alveolar bone loss
they can also be invaluable for treatment
planning and in monitoring the long-term
stability of periodontal health. By providing
information on other pathologies, such as
periapical pathology, pulpal/furcation
involvements and caries, radiographs also
provide a guide to the overall prognosis of
teeth.
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od_practitioners_guide_2016.pdf?v=3
 This guide does not aim to dictate the
choice of radiographs as each patient will
have their own unique clinical presentation
but care should be taken to ensure that
each exposure is clinically justified, of
suitable quality to be useful and provide
clear benefit to the patient.
 Initial presentation
 The number and type of radiographs required
will depend on your findings during the clinical
examination. You may choose to take
radiographs as part of your special
investigations on completion of the BPE.
Although if a detailed periodontal chart is
required you may decide to wait and use this
additional information to help decide which
views would be most appropriate.
https://www.bsperio.org.uk/publi BASIC PERIODONTAL EXAMINATION
cations/downloads/107_084422 (BPE)
_bpe-guidelines-2011.pdf
 Radiographs can also be useful to track
changes in bone levels over time, for
example in areas of furcation involvement
or in patients where there is uncertainty as
to the aggressiveness of the disease
process.
 Clinical need should determine the
frequency of repeat radiographs. Bone
loss is slow to become apparent on
sequential radiographs
Which radiographs?
Horizontal bitewings
 Bitewing radiographs are likely to be taken
routinely for assessing caries. They may
also give early warning of localised bone
loss, the presence of poorly contoured
restorations and subgingival calculus. The
normal positioning of the film should
automatically ensure a non-distorted view
of bone levels in relation to the cemento-
enamel junction (CEJ).
Radiographic features of the periodontium on a horizontal
bitewing film. In health the alveolar crest is roughly
horizontal, about 2-3mm apical to and parallel to a line
joining adjacent CEJs.
Vertical bitewings
 Correctly positioned, this type of radiograph
provides a non-distorted view of bone levels in
relation to CEJs, in opposing arches. Vertical
bitewings can provide better visualisation of the
bone level than horizontal bitewings. However,
they can be difficult to position accurately in
patients especially those with more shallow
palates. Selected periapicals may be more
appropriate where assessment of apical status
could be important.
Periapicals
 The gold standard radiograph for periodontal
assessment is a periapical radiograph taken
using a long-cone paralleling technique.
Correctly positioning this radiograph will give an
accurate, non-distorted two dimensional picture
of bone levels in relation to both CEJs and total
root length. This technique involves the use of a
beam aiming device which helps achieve better
and more consistent results.
 Visualising root anatomy in its entirety can
be very useful in assessing bone levels in
relation to total root length in:
 Assessing prognosis
 Helping to assess furcation involvements
 Identifying possible endodontic
complications
Periapical radiograph showing both
horizontal and angular bony defects.
Perio-endo lesion
 Dental panoramic
tomographs (DPTs)/OPG
 There is no case for routine screening with
panoramic films. The yield of information is
low for screening given the radiation
dosage. In complex cases where there are
a variety of dental concerns a DPT could
be considered.
A DPT can be useful for bone level assessment in
complex cases where there are a variety of dental
concerns
 Periapical vs panoramic
radiographs
 The choice of panoramic vs. intra-oral
periapical radiographs may depend on a
range of factors including preference and
availability. In general, full mouth
periapical radiographs using a paralleling
technique, give more accurate and
detailed assessment of periodontal bony
defects.
 In contrast, a good quality panoramic
radiograph is quicker, less uncomfortable,
and may provide useful assessment of
bone levels and other pathologies.
Panoramic radiographs might need to be
supplemented with periapical views
especially in the anterior sextants due to
the likelihood of image distortion in these
regions
 Radiographic periodontal
assessment
 Medico-legally it is important that you
report your radiographic findings in the
clinical notes and this should include an
assessment of the image quality.
 Periodontally, radiographs should be assessed
for:
• Degree of bone loss: if the apex is visible then
bone loss should be measured and reported as
a percentage
• Pattern or type of bone loss: e.g. horizontal bone
loss or angular (vertical) defects
• Presence of furcation defects
• Presence of subgingival calculus
• Other features: e.g. perio-endo lesions; widened
periodontal ligament spaces; abnormal root
length or root morphology; overhanging
restorations
Calculating percentage bone
loss
  Radiographs can also be helpful for assessing
expectations of treatment. For example:
• If there are angular defects more than 3mm deep
you should not expect dramatic pocket
reductions with simple non-surgical therapy
• Multiple angular defects and furcation
involvement suggest a complex treatment need
and consideration for referral.

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od_practitioners_guide_2016.pdf?v=3
 Use of cone beam computed
tomography in periodontology
(CB CT)
 However, in the case of bone destruction, radiographs
are valuable diagnostic tools as an adjunct to the clinical
examination. Two dimensional periapical and panoramic
radiographs are routinely used for diagnosing
periodontal bone levels. In two dimensional imaging,
evaluation of bone craters, lamina dura and periodontal
bone level is limited by projection geometry and
superpositions of adjacent anatomical structures.
https://www.ncbi.nlm.nih.gov/pmc/articles/P
MC4037540/
 Those limitations of 2D radiographs can
be eliminated by three-dimensional
imaging techniques such as computed
tomography. Cone beam computed
tomography (CBCT) generates 3D
volumetric images and is also commonly
used in dentistry. All CBCT units provide
axial, coronal and sagittal multi-planar
reconstructed images without
magnification.
 Also, panoramic images without distortion and
magnification can be generated with curved
planar reformation. CBCT displays 3D images
that are necessary for the diagnosis of intra bony
defects, furcation involvements and
buccal/lingual bone destructions. CBCT
applications provide obvious benefits in
periodontics, however; it should be used only in
correct indications considering the necessity and
the potential hazards of the examination.
https://www.ncbi.nlm.nih.gov/pmc/articles/P
MC4037540/
https://www.ncbi.nlm.nih.gov/pmc/articles/P
MC4037540/
 Bacterial examination of
periodontal disease
 Bacterial examination methods that detect
the presence of bacteria, but not the
amount, are termed qualitative
examinations

https://www.researchgate.net/publication/2
21923751_Microbiological_Diagnosis_for_
Periodontal_Diseases
 Microbiological examinations for the
purpose of antibiotic selection
 Periodontal tissue debridement and root planing
are the initial therapeutic approaches for
periodontal disease. However, mechanical
periodontal debridement can have poor
therapeutic efficacy in some cases, owing to the
invasion of periodontopathic bacteria into the
periodontal tissue.
 In such cases, antibiotic therapy is often
effective (Slots et al., 2004). Antibiotics can be
chosen based on the specific pathogens
identified by microbiological examination.
Porphyromonas gingivalis, A.
actinomycetemcomitans, T. forsythia, and T.
denticola are common target bacteria. In next
table it’s shows the recommended antibiotics
according to bacterial type.
 https://pdfs.semanticscholar.org/8bc5/338
98340238d27bece3a87e1cdb4ad39d934.
pdf