358
PART PAR T 6 Treatment Treatment of Periodontal Disease Di sease
the root suggests the presence of a periodontal abscess!
Figure 30-32 30-32 Gingival Gingival abscess between upper lateral incisor and canine.
An apical abscess may spread along the lateral aspect of the root to the gingival margin. owever! when the ape" and lateral surface of a root are involved by a single lesion that can be probed directly from the gingival margin! the lesion is more li#ely to have origi$ nated as a periodontal abscess. Radiographic %ndings are helpful in di&erentiating between a periodontal and a periapical lesion 'see (hapter )*+. ,arly acute periodontal and periapical abscesses present no radiographic changes. -rdinarily! a radiolucent area along the lateral surface of
whereas apical rarefaction suggests a periapical abscess. owever! acute peri$ odontal abscesses that show no radiographic changes often cause symptoms in teeth with long$standing! radiographically detectable periapical lesions that are not contributing to the patient3s com$ plaint. (linical %ndings! such as the presence of e"tensive caries! poc#et formation! lac# of tooth vitality! and the e"istence of conti$ nuity between the gingival margin and the abscess area! often prove to be of greater diagnostic value than radiographic appearance. A draining sinus on the lateral aspect of the root suggests peri$ odontal rather than apical involvement4 a sinus from a periapical lesion is more li#ely to be located further apically. owever! sinus location is not conclusive. /n many instances! particularly in chil$ dren! the sinus from a periapical lesion drains on the side of the root rather than at the ape" 'see (hapter 5*+.
1or more information on laboratory aids to clinical diagnosis! please visit the companion website at www.e"pertconsult.com.
References can be found on the companion website at www.e"pertconsult.com.
(/,0(, TRA01,R mouth series of radiographs ta#en within the last years with any needed updates is necessary to achieve a correct diagnosis evaluation and prepare the appropriate treatment plan. that is recorded in the chart. This! at a minimum! includes Periodontal screening and recording systems have little value probing in managing patients in a private practice because they do not data on si" surfaces on each tooth! as well as recording give su7cient speci%c data for individual patient treatment gingival planning. recession and bleeding on probing. -ther parameters that need to be recorded include mobility! furcation involvement! mucogin$ gival de%ciencies! pla2ue scores! open contacts! and e"amination of functional occlusal relationships. A comprehensive medical and dental history must accompany the clinical protocol. A full$ All patients should have a comprehensive periodontal
(APT,R )* Radiographic Aids in the Diagnosis of Periodontal Disease Sotirios Tetradis, Fermin A. Carranza, Robert C. Fazio, and Henry H. Takei
CHAPTR !"T#$% %!R&A# $%TRD%TA# '!% RAD$!(RAPH$C TCH%$)"* '!% D*TR"CT$!% $% PR$!D!%TA# D$*A* 8one 9oss Pattern of 8one Destruction RAD$!(RAPH$C APPARA%C !F PR$!D!%TA# D$*A* Periodontitis /nterdental (raters 1urcation /nvolvement
Refer to the
Periodontal Abscess (linical Probing 9ocali:ed Aggressive Periodontitis Trauma from -cclusion ADD$T$!%A# RAD$!(RAPH$C CR$TR$A 'online only+ *+#TA# D$*T"R'A%C* &A%$F*TD $% TH ,A* 'online only+ D$($TA# $%TRA!RA# RAD$!(RAPH. AD/A%CD $&A($%( &!DA#$T$*
companion website at www.e"pertconsult.com for additional content.
ome %gures may be out of numeric order in this printed chapter.
adiographs are valuable for diagnosis of periodontal disease! estimation of severity! determination of prognosis! and evaluation of treatment outcome. However, radiographs are an adjunt to the !inia! e"amination, not a substitute #or it. Radiographs demonstrate changes in calci%ed tissue4 they do not reveal current cellular activity but rather re;ect the e&ects of past cellular e"perience on the bone and roots.
%!R&A# $%TRD%TA# '!% ,valuation of bone changes in periodontal disease is based mainly on the appearance of the interdental bone because the relatively dense root structure obscures the facial and lingual bony plates. The
radiopa2ue line ad
tooth surfaces and the level of the cementoenamel The faciolingual diameter of the bone is related to the width of the pro"imal root surface. The angulation of the crest of the interdental septum is generally parallel to a line between the (,=s of the appro"imating teeth 'see 1igure )*$*+. ?hen there is a di&erence in the level of the (,=s! the crest of the interdental bone appears angulated rather than hori:ontal.
RAD$!(RAPH$C TCH%$)"* /n conventional radiographs! periapical and bite$wing pro
o&er the most diagnostic information and are most commonly used in the evaluation of periodontal disease. To properly and accurately depict periodontal bone status! proper techni2ues of e"posure and development are re2uired. The bone level! pattern of bone destruc$ tion! PD9 space width! )) as well as the radiodensity! trabecular pattern! and marginal contour of the interdental bone! vary by modifying e"posure and development time! type of %lm! and "$ ray angulation. *@ tandardi:ed! reproducible techni2ues are re2uired to obtain reliable radiographs for pretreatment and posttreatment comparisons. *6!!)*
35 310
PART 6 Treatment of Periodontal Disease
Prichard) established the following four criteria to determine ade2uate angulation of periapical radiographsB *. The radiograph should show the tips of molar cusps with little or none of the occlusal surface showing. . ,namel caps and pulp chambers should be distinct. ). /nterpro"imal spaces should be open. . Pro"imal contacts should not overlap unless teeth are out of line anatomically. 1or periapical radiographs! the long$cone paralleling techni2ue most accurately pro Periapical radiographs fre2uently do not reveal the correct rela$ tionship between the alveolar bone and the (,=. This is particularly true in cases in which a shallow palate or ;oor of the mouth does not allow ideal placement of the periapical %lm. 8ite$wing pro
R
Figure 32-2 (rest of interdental bone normally parallel to a line drawn between the cementoenamel
the radiopa2ue lamina dura around the roots and interdental bone.
A
accounted for by "$ray angulation. tions o&er an alternative that better images periodontal bone levels. 1or bite$wing radiographs! the %lm is placed behind the crowns of the upper and lower teeth parallel to the long a"is of the teeth. The "$ray beam is directed through the contact areas of the teeth and perpendicular to the %lm. )5 Thus the pro
'!% D*TR"CT$!% $% PR$!D!%TA# D$*A*
Amount. Radiographs are an indirect method for determining
the amount of bone loss in periodontal disease4 they image the amount of remaining bone rather than the amount lost. The amount of bone lost is estimated to be the di&erence between the physio$ logic bone level and the height of the remaining bone. The distance from the (,= to the alveolar crest has been ana$ ly:ed by several investigators. *!*!@ ost studies! conducted in adolescents! suggest a distance of mm to re;ect normal periodon$ tium4 this distance may be greater in older patients. Distribution. The distribution of bone loss is an important
diagnostic sign. /t points to the location of destructive local factors
,arly destructive changes of bone that do not remove su7cient minerali:ed tissue cannot be captured on radiographs. )!!5 There$ fore slight radiographic changes of the periodontal tissues suggest that the disease has progressed beyond its earliest stages. The ear!iest signs o# periodonta! disease must be deteted !inia!!y.
'one #oss The radiographic image tends to underestimate the severity of bone loss.C!) The di&erence between the alveolar crest height and the radiographic appearance ranges from E mm to *.6 mm! @ mostly
B
Figure 3-2 (omparison of long$cone paralleling and bisection$ of$the$angle techni2ues. A 9ong$cone paralleling techni2ue! radiograph of dried specimen. ' 9ong$cone paralleling techni2ue! same specimen as A4 mooth wire is on margin of the facial plate and #notted wire is on the lingual plate to show their relative C posi$ tions. C 8isection$of$the$angle techni2ue! same specimen as A and '4 D 8isection$of$the$angle techni2ue! same specimen. 8oth bone margins are shifted toward the crown! the facial margin 'smooth wire+ more than the lingual margin '#notted wire+! creat$ ing the illusion that the lingual bone margin has shifted apically. &Courtesy (r. $enjamin )atur, Hart#ord, CT.'
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