OD DX & TX PLANNING - MODULE 6 ● The edentulous areas do not compromised the physiologic

PROSTHODONTIC DIAGNOSTIC INDEX (PDI) FOR THE support of the abutments. Edentulous areas may include
PARTIALLY EDENTULOUS AND THE COMPLETELY any anterior maxillary span that does not exceed two
DENTATE PATIENT incisors, any anterior mandibular span that does not
exceed four incisors, any posterior span (maxillary or
Before any prosthodontic procedure: Explain to the px their mandibular) that does not exceed two premolars, or one
present condition, and how would you know their present condition premolar and one molar or any missing canine (maxillary
and how can you predict the prognosis? Standardized parameters or mandibular)
and indices to help you determine if px has an ideal, moderately or 2. Condition of the abutments is moderately compromised:
severely compromised situation Abutments in one or two sextants have insufficient tooth structure
to retain or support intra-coronal or extracoronal restorations.
Prosthodontic Diagnostic Index (PDI) for the Partially Abutments in one or two sextants require localized adjunctive
Edentulous Areas therapy. The need for extra/intracoronal restoration before giving
Pertains to upper or a lower arch or even upper and lower arches a prosthodontic tx
3. Occlusion is moderately compromised: Occlusal correction
4 standardized criteria: requires localized adjunctive therapy. Maxillomandibular
1. Location relationship: Class I molar and jaw relationships. Adjunctive
2. Abutment condition therapy is needed to restore maxillomandibular relationship
3. Occlusal scheme 4. Residual ridge structure conforms to the Class II complete
4. Residual ridge edentulism description
Class I
- is characterized by ideal or minimal compromise in the Class III
location and extent of edentulous area (which is confined - Is characterized by substantially compromised location
to a single arch), abutment conditions, occlusal and extent of edentoulous areas in both arches, abutment
characteristics, and residual ridge conditions condition necessitating substantial localized adjunctive
- all four of the diagnostic criteria are favorable therapy, occlusal characteristics necessitating
1. The location and extent of the edentulous area are ideal or re-establishment of the entire occlusion without a change
minimally compromised: the edentulous area is confined to a in the occlusal vertical dimension, and residual ridge
single arch. The edentulous area does not compromise the conditions
physiologic support of the abutments (All of the criteria are 1. The location and extent of the edentulous areas are substantially
deemed to be favorable — edentulous are should be confined only compromised: Edentulous areas may be present in one or both
in a single arch either upper or lower; support of abutments (pdl, arches
bone, gingiva, and surrounding mucosa) are all in physiologic ● Edentulous area compromise the physiologic support of
health) the abutments bone resorptions may be present, loss of pd
The edentulous area may include any anterior maxillary support
span that does not exceed two incisors, any anterior mandibular ● Edentulous areas may include any posterior maxillary or
span that does not exceed four missing incisors, or any posterior mandibular edentulous area greater than three teeth of two
span that does not exceed two premolars or one premolar and one molars or anterior and posterior edentulous areas of three
molar. or more teeth
2. The abutment condition is ideal or minimally compromised, 2. The condition of the abutments is moderately compromised:
with no need for preprosthetic therapy (one to one ratio for crown Abutments in three sextants have insufficient tooth structure to
and root, is there horizontal bone resorption or vertical root retain or support intracoronal or extracoronal restorations
resorption? Do not need to rehabilitate or reconstruct) ● Abutments in three sextants require more substantial
3. The occlusion is ideal or minimally compromised, with no need localized adjunctive therapy (i.e. periodontal, endodontic
for preprosthetic therapy; maxillomandibular relationship consists or orthodontic procedures) Abutments have a fair
of Class I molar and jaw relationships prognosis
4. Residual ridge morphology conforms to the Class I complete 3. Occlusion is substantially compromised: Requires
edentulism description which is a high well-rounded reestablishment of the entire occlusal scheme without an
accompanying change in the occlusal vertical dimension.
Class II Maxillomandibular relationship: class II molar and jaw
- Is characterized by moderately compromised location relationships (require you to have minimal orthodontic procedure)
and extent of edentulous areas in both arches, abutment 4. Residual ridge structure conforms to the Class III complete
conditions necessitating localized adjunctive therapy, edentulism description
occlusal characteristics necessitating localized adjunctive
therapy, and residual ridge conditions Class IV
1. The location and extent of the edentulous area are moderately - Is characterized by severely compromised location and
compromised: Edentulous areas may exist in one or both arches extent of edentulous areas with guarded prognosis,
 abutments requiring extensive therapy, occlusion - Low frenum attachments can be of good use meaning
characteristics necessitating reestablishment of the attachment is not extending up to ridge because higher
occlusion with a change in the occlusal vertical frenum may cause dislodging force
dimension, and residual ridge conditions - Absence of undercuts shallow undercuts can be beneficial
1. The location and extent of the edentulous areas result in severe for resistance of dislodging forces
occlusal compromise: - Abundant attached keratinized mucosa
● Edentulous areas may be extensive and may occur in both - Adequate alveolar height
arches
● Edentulous areas compromise the physiologic support of - The size of the residual ridge is reduced most rapidly in the first 6
the abutment teeth, and so the prognosis is guarded months, but the bone resorption activity continues throughout life
● Edentulous areas include acquired or congenital at a slower rate, resulting in removal of a large amount of jaw
maxillofacial defects. At least one edentulous area has a structure
guarded prognosis
2. Abutments are severely compromised: Abutments in four or - This unique phenomena has been described as RESIDUAL
more sextants have insufficient tooth structure to retain or support RIDGE RESORPTION (RRR)
intracoronal or extracoronal restorations. Abutments in four or
more sextants require extensive localized adjunctive therapy. - The rate of RRR is different among persons and even at different
Abutments have a guarded prognosis. sites in the same person
3. Occlusion is severely compromised: reestablishment of the
entire occlusal scheme, including changes in the occlusal vertical Rate of resorption
dimension, is necessary. Maxillomandibular relationship: Class II, ● Most rapid in the first year after extraction and can be as
division 2, or class III molar and jaw relationships high as 4.5mm/year
4. Residual ridge structure conforms to the Class IV complete ● After healing of residual ridge, annual rate of reduction in
edentulism description. Other characteristics include severe height is about 0.1-0.2mm in mandible
manifestations of local or systemic disease, including sequelae ● Annual rate of reduction in height is about 4x greater in
from oncologic treatment, maxillomandibular dyskinesia and/or mandible than in maxilla
ataxia, and refractoriness (a patient’s presenting with chronic Direction of Bone Resorption
complaints after appropriate therapy) - Maxilla resorbs upward and inward to become progressively
smaller because of the direction and inclination of the roots of the
THE OFFICIAL CLASSIFICATION SYSTEM FOR teeth and the alveolar process
EDENTULISM DEVELOPED BY THE AMERICAN - The opposite is true of the mandible, which inclines outward
COLLEGE OF PROSTHODONTICS and becomes progressively wider
- This progressive change of the edentulous mandible and maxilla
Residual alveolar ridge is the portion of the alveolar ridge and its makes many patients appear prognathic
soft tissue covering which remains following the removal of or loss
of teeth FOUR DIAGNOSTIC CRITERIA
a) Mandibular bone height,
Ideal Maxillary Ridge b) Maxillomandibular relationship
- Abundant keratinized attached tissue for your dentures to c) Maxillary residual ridge morphology,
be stable and comfortable for the patient d) Muscle attachments
- Square arch minimal movement
- U-shaped in cross-section better The PDI for the Edentulous Class 1 Patient
- Moderate palatal vault moderate in depth so that it can be - A patient who presents with ideal or minimally
easily replicated during impression compromised complete edentulism that can be treated
- Absence of undercuts promote unnecessary trauma successfully by conventional prosthodontic techniques
- Frenal attachments distal from crestal ridges as much as a) a residual mandibular bone height of at least 2 millimeters
possible so as not to impede on placement of dentures measured at the area of least vertical bone height
- Well defined hamular notches so that you would know b) maxillomandibular relationship permitting normal tooth
clearly when to end the border of posterior buccal area articulation and an ideal ridge relationship
c) maxillary ridge morphology that resists horizontal and vertical
Ideal Mandibular Ridge movement of the denture base
- Well defined retromolar pad si you can approximate d) muscle attachment location conducive to denture base stability
easily where to terminate setting of molars and this will and retention
dictate the height of occlusion
- Blunt mylohyoid ridge The PDI for the Edentulous Class 2 Patient
- Deep retromylohyoid space
 - A patient who presents moderately compromised
complete edentulism and continued physical degradation
of the denture supporting anatomy
a) Residual mandibular bone height of 16-20mm measured on the
least vertical bone height
b) a maxillomandibular relationship permitting normal tooth
articulation and an appropriate ridge relationship’
c) a maxillary residual ridge morphology that resist horizontal and
vertical movement of the denture base and
d) muscle attachments that exert limited compromise on denture
base stability and retention

The PDI for the Edentulous Class 3 Patient

- A patient presents with substantially compromised
complete edentulism and exhibits
a) limited interarch space of 20 mm and/or temporomandibular
disorders
b) Residual mandibular bone height of 11, 15 millimeters measures
at the are at least vertical bone height
c) An Angle class I, II or all maxillomandibular relationship,
d) Muscle attachments that exert a moderate compromise on
denture base stability and retentions,
- A maxillary residual ridge morphology providing minimal
resistance movement of the denture base

The PDI for the Edentulous Class 4 Patient

- A patient who presents with the most debilitated form of
complete edentulism where surgical reconstruction is
usually indicated and specialized prosthodontic
techniques are required to achieve an acceptable outcome.
a) a residual mandibular bone height of 10 millimeter or less
b) Angle class I, II, or III maxillomandibular relationship
c) A maxillary residual ridge morphology providing no resistance
to movement of the denture base
d) muscle attachments that exert a significant compromise on
denture base stability and retention
ORAL DX & TX PLANNING - MODULE 7 Gingiva
PARAMETER NORMAL DISEASED
Examination of the Periodontium S
Periodontium consists of soft tissues such as periodontal ligament
and gingiva while hard tissues such as alveolar bone and Color Pink, pink with Red, bluish red-
cementum melanin cyanotic, whitened
pigmentation
CURETTE CLASSIFICATION
Cont Papillary Papillae fill Blunted, bulbous,
• Used for anterior teeth: Gracey ½, 2/4 and 5/6 ours embrasures, cratered
• Used for facial surfaces of posterior teeth: Gracey 7/8 pointed, pyramidal
• Used for mesial surfaces of posterior teeth: Gracey 11/12
• Used for lingual surfaces of posterior teeth: Gracey 9/10 Marginal Knife edged Rolled
• Used for distal surfaces of posterior teeth: Gracey 13/14
Consistency Resilient, firm, Edematous, soft and
non-retractable spongy, air retractable
GINGIVA
with air
Marginal "unattached" gingiva
• it is the border of the gingiva surrounding the teeth in collar like Texture Stippled Smooth and shiny
fashion when you probe you must thru the unattached gingiva (loss of stippling
smoothly
Attached gingiva Position At the More coronal, more
cemento-enamel apical
• It is continuous with the marginal gingiva.
junction
• It is firm, resilient and tightly bound to the underlying alveolar
bone. Create a resistance when you insert the probe
Interdental gingiva
• It occupies the interproximal space beneath the area of the tooth
contact ( original embrasure )
• It usually consists of two papillae , one facial and “col”
Triangular shaped gums in between interproximal spaces

Gingivitis - slightly reddish

Periodontitis - level is lower and more apical; presence of
calculator deposits
Advanced periodontitis - exposed cementum
Gingival recession - associated with bone resorption
Pericoronitis - patients with impacted tooth or tooth that are
erupting
Gingival enlargements - cause might be drug-induced, lower
immune system
Gingival abscess - infiltrations of pus and has bacteria
Exostosis on attached gingiva - torus

With the width of attached gingiva, there should be an average of

2mm; attached gingiva for upper is greater than the lower
Attached gingiva would be greater at incisors rather than
posterior; canines and premolars have the least width of attached
gingiva Desquamation
Gingival bleeding is not caused by gingivitis alone but some has
underlying conditions that involve blood dyscrasia
Dilantin pink Tough gingival Inflammation
Gingival overgrowths is a consequence of calcular deposits or bad enlargement may give rise to
hyperplasia
hygiene redness and
Racial pigmentation sometimes race would dictate color of the bleeding
gingiva due to melanin
Gingival blisters might be brought about by trauma, resultant of Pubertal Bluish red Gingival Bleeds easily
existing periapical abscess that created a fistula gingivitis enlargement

• Simple gingivitis resolved by ordinary oral prophylaxis; Pregnancy Same as Tough gingival Inflammation
gingivitis pubertal enlargement may give rise to
reinforcing oral hygiene of patient gingivitis redness and
• Complex gingivitis bleeding
Vincent's infection
Alteration of Alteration of Clinical Symptom Leukemic gingivitis
color form Feature/s local/general Can be seen in patients with
leukemia
Grayish Necrosis of Punched out Pain of
yellow gingival interdental varying Underneath, you would see calcular
pseudo-mem margins & papilla degrees, deposits
brane interdental sialorrhea
papilla feeling of
tooth
wedging, foul Alteration of color Alteration of form Clinical Feature/s
odor
Bluish red to pink Pronounced Soft & spongy,
enlargement may cover teeth
Hyperplastic gingivitis
Simple hyperplastic gingivitis
GINGIVOSTOMATITIS
Usually seen in pregnant women due to
Chronic desquamative gingivitis
hormonal changes

Alteration of Alteration of Clinical Symptom

color form Feature/s local/general
Alteration of Alteration of Clinical Symptom
Bluish red Gingival Soft and Slight pain color form Feature/s
related to enlargement spongy due to irritant
inflammatory Grayish to Peeling of Patch of Pain
response blue to epithelium speckled depending on
brilliant red discoloration severity

Hereditary gingivofibromatosis
Herpetic gingivostomatitis
only the incisal portion can be seen
Caused by herpes

Alteration of Alteration of Clinical Symptom

color form Feature/s local/general
Alteration Alteration Clinical Symptom
Pale pink Firm Pronounced Tender to of color of form Feature/s
enlargement enlargement palpation
and very covering the Fiery red Ruptured Rupture Regional
dense teeth vesicular creates lymphadenopat
eruptions, ulcers hy palpate
diffuse submandibular
Gingivitis modified and sublingual
by systemic factors are of the neck;
1) Dilantin palpation
hyperplasia through
2) Pubertal bilateral
gingivitis
3) Pregnancy gingivitis
GINGIVAL ATROPHY AND RECESSION - Bleeding on probing: no or yes. If yes, slight, moderate,
A. Chronic atrophic senile gingivitis or severe
B. Atrophic gingivitis - Evaluation of probing depth: by use of the calibrated
periodontal probe the clinician can evaluate the depth of
the periodontal pocket and attachment level
Alteration of color Alteration of form Clinical Feature/s
Roentgenographic evaluation:
Pale and grayish Thin and atrophic Easily traumatized Evaluation of bone involvement by x-ray examination may reveal
white cheek has milky one of the following:
appearance - Cup shape resorption of the alveolar crest
- Horizontal resorption is an indication for the presence of
PERIODONTITIS periodontal destruction e.g. chronic periodontitis
- Vertical bone resorption usually associated with
aggressive periodontitis

Examination for Calculus

Alteration of Alteration of Clinical Symptom Supragingival calculus
color form Feature/s • derived from plaque which
calcifies above the gingival
Red or bluish Soft and Periodontal localized
margin.
red spongy with pockets
rolled thick • located principally in close proximity to the openings of the
margins major salivary glands.
•It is creamy, white in colour and comparatively easy to remove
• STREP SANGUIS EARLY BACTERIAL COLONIZER
Periodontal Examination
The importance of periodontal examination is to determine the
Subgingival calculus
following:
•calculus which has commenced its calcification subgingivally,
1. Whether if patient has a healthy or diseased periodontium
irrespective of its final location.
2. Know the extent of damage and if there are any
• It is dark in colour due to the inclusion of blood pigments.
pathologic changes present, what are the remedies that
must be done
3. Identify what characteristics are already present during
periodontal exam - determine definitive diagnosis,
etiology, prognosis, and several treatment plans

Means of clinical examination:

Inspection:
- Gingival color: pink, red, bluish, or other color variation
- Gingival contour: both marginal and papillary: normal,
rounded, crater or other anatomical variation
- Gingival size: normal size, gingival enlargement or
gingival recession
- Position of the gingival: adjacent to cemento-enamel PERIODONTAL PROBING
junction or receded coronal to cement enamel junction - Periodontal probing is
Palpation: accomplished for all surfaces
- Gingival consistency: normal, edematous, fibrotic or of every tooth in the dentition.
fiber edematous bidigital or bimanual palpation - During probing, a
- Gingival texture: “stippling”: normal, decrease, increase periodontal probe should be
or lack of stippling no stippling - edematous used with gentle pressure and it should be "walked" around the
- Tooth mobility: by using handles of two dental entire circumference of each tooth.
instruments apply alternate pressure on the buccal or - examining surfaces of tooth (facial, mesial, distal, buccal or
lingual surface of each tooth lingual)
- Migration: is a pathological movement of the teeth in - probe must be inserted parallel to long axis
labial, distal, mesial or supra occlusion. Migration is - examining of interproximal areas: you insert the probe at 10-15
common feature of some periodontal disease e.g. degree angle to determine if there is presence of interdental craters
aggressive periodontal, it may relate to some habit, e.g. Three Types Of Probes
tongue thrusting
Probing:
 No presence of periodontal ocket; probing depth is normal but
presence of the three mentioned

Gingival recession
- the distance from cemento-enamel junction to the gingival margin
- important to the periodontal examination because it accurately
indicated the total amount of attachment loss
WHO - standardized probe (volunteer works) - a tooth can have attachment loss without having a pocket
Presence of cementum

Porbe must be inserted parallel to the long axis of tooth and probe
should be at a 25 degree angle

In INTERPROXIMAL AREAS, the pocket

should be checked at the midpoint under the
contact area 10-15 degrees so you would know if
there is presence of interdental craters; probing The gingiva in picture 1 is from
depth is recorded for each teeth thins tissue biotype and is more
6 locations: buccal, lingual, mesiobuccal, prone to recession than the gingiva
mesiobuccal, distobuccal, mesiolingual, distolingual in picture 2 (medium) and 3
(thick)
A probing force of 25 grams (0.75 Newtons)
have been found to be well tolerated and
accurate
In doing probing, you should not exert too much
force because sumosobra sa attached gingiva

Periodontal Pockets
- Biologic or histologic depth: is the distance between the gingival
margin and the base of the pocket
- Probing depth: is the distance to which the probe penetrate into
the pocket
Probing depth > histologic depth
Extent of Disease
- Normally registered a probing depth is within the range of 0-3
Low category - involve 1-10 sites
mm between the gingival margin and the terminal end of the probe
Medium category- 11-20 sites
- In consequence a probing depth of 4mm or more, due to loss of
High category - more than 20 sites
periodontal attachment is taken to signify an increased probing
depth or pocket
Examination for Marginal Gingival Inflammation
The common signs of inflammation which occur around the
- Deepened sulcus (normal is 3mm)
gingival margin include:
- SUPRABONY POCKET: base of the pocket is
- Swelling (with change in contour, texture and consistency of
above the alveolar bone (horizontal bone loss)
gingiva)
- INFRABONY/INTRABONY POCKET: base of
- Redness
the pocket is below the alveolar bone (vertical/angular
- Bleeding
bone loss)
● More consistently reliable method
● Placing a periodontal probe at the opening of the gingival
sulcus in contact with the gingiva is sufficient disruption
to the gingiva to evoke bleeding in those sites at which
the gingiva is inflamed
Recession + Pocket application of force with an instrument handle on the tooth crown
- if recession and a probing depth directed in an apical direction.
coexist at one site, the amount of
attachment front he CEJ is the sum TOOTH MOBILITY
of the two figures • The principal causes of tooth mobility are los alveolar bone,
If disease still progresses then it inflammatory changes in the periodontal ligament, and trauma
will result to recession and pd from occlusion
pocket • Tooth mobility caused by inflammation and trauma from
occlusion may be correctable. However tooth mobility resulting
False Pocket from loss of alveolar bone is not likely to be corrected.
- if the gingival margin is coronally
placed and lies nearer the occlusal Horizontal tooth mobility -
surface or incisal edge of the tooth than the ability to move the tooth in
its usual placement, a probing depth of a facial-lingual direction in its
more than 3mm can often be registered socket.
- in those circumstances in which this is Vertical tooth mobility - the
encountered (e.g. partially erupting ability to depress the tooth in its
third molars) and where there has been socket,
no loss of periodontal attachment, such
an increased probing depth is termed a “false pocket” Mobility Classifications

Clinical Attachment Level (CAL)

- Clinical attachment loss is the distance
from cemento-enamel junction to the base of
the pocket
- represents the best measure of disease
severity in terms of loss of support for the
teeth
- the CAL provides an estimate of a
tooth’s stability and the loss of bone
support
The blogger the CAL, the more severe the Furcation involvement
disease is. • Furcation involvement
indicates a serious
Slight (mild) periodontitis periodontal condition that
- Periodontal destruction is generally considered slight can affect multi-rooted teeth.
when no more than 1 to 2 mm of CAL has occurred • As a result, abscesses,
Moderate periodontitis progressive attachment loss,
- Periodontal destruction is generally considered moderate and deep periodontal pockets
when 3 to 4 mm of CAL has occurred may develop and be undetected
Severe periodontitis defined as an area of bone loss at this branching point of a tooth
- Periodontal destruction is considered severe when 5 mm root.
or more of CAL has occurred Very serious periodontal condition already;

Tooth mobility
- An indicator of bone loss around the
tooth
- Mobility is detected by using the end
of the handle of two instruments (e.g.
mirror and periodontal probe)
I Detectable increased tooth mobility not
exceeding 1 mm of bucco-lingual movement.
II Detectable increased tooth mobility in excess of I mm but less
than 2 mm of bucco-lingual movement.
III Detectable increased tooth mobility in excess of 2 mm
bucco-lingual movement/clinically evident apical movement upon
 ASSESSMENT OF SEVERITY OF PERIODONTITIS IS
BEST DETERMINED BY:
•RADIOGRAPHIC ASSESSMENT OF BONE LOSS
(OVER-ALL)
•PERIODONTAL PROBING DEPTH (IF CLINICAL SIGN)

Next meeting daw to..

PERIODONTAL SCREENING AND RECORDING SYSTEM
• A PSR examination can help to identify patients who need a
comprehensive periodontal assessment.
•The results of this screening examination are used to separate
patients into two broad categories:
~those who have periodontal health or gingivitis and those who
have periodontitis.

Stages of Periodontitis