2025 Catalog: All Courses

September 2025 Periodontal Pearl:

Assessing and Diagnosing Periodontal Disease

•   What is periodontal health?
•   What is periodontal disease?
•   How to assess periodontal disease?
•   Stage and Grade Periodontal Health

What is periodontal health?
Periodontal health is the state of the supporting parts of periodontium to include the gingiva, periodontal ligaments, cementum, and alveolar bone. These parts are assessed by the measurements of clinical attachment level [CAL], probing depths, bone loss, mobility, recession, and bleeding on probing to evaluate the presence of signs and symptoms of periodontal disease. A healthy periodontium is usually uniformed pink in color variations based on race, fits snug around the teeth, stippled in texture, sharp papilla that fills interdental space, and absence of disease and inflammation.

What is periodontal disease?
Periodontal disease is a chronic inflammatory disease of the periodontium that is caused by infectious bacteria. The two most common inflammatory oral infections are gingivitis and periodontitis.

Gingivitis is produced by induced biofilm and plaque and non-induced biofilm and plaque [genetics; viral; fungal; immune conditions; reactive processes; neoplasms; endocrine nutritional, and metabolic diseases; traumatic lesions; and gingival pigmentation] infections that are confined to the gingiva. ¹ The gingiva is generally characterized as painless, redness, swollen, bleeding and tenderness to touch with the absence of periodontal attachment loss, bone loss, and mobility, and can be reversed to a healthy state.

Periodontitis is bacteria-induced inflammation of the periodontium to include the gingiva, periodontal ligaments, bone, and cementum and can affect health conditions, such as diabetes, cardiovascular disease, preterm and/or low birth weight, and respiratory diseases while these health conditions can affect the periodontium, as well. If periodontal disease is left untreated, the risk of becoming edentulous increases. Periodontitis is irreversible; however, the progression of the active disease can be arrested.

Photo 1
Gingivitis: Periodontitis:


How to assess periodontal disease?
Gingivitis can be assessed as a localized, site-specific area or as a generalized case [GC] by assessing the severity of inflammation and bleeding of the gingiva known as gingival index [GI]. When gingivitis is assessed as localized, site-specific, the diagnosis is considered “gingivitis site,” visual gingival assessment and bleeding sites may be ? 10 but ? 30 and GC is considered when visual gingival assessment has > 30 bleeding sites and probing depths ? 4mm.

Gingival Index [LoeProbe and Silness, 1963]: Scores based on inflammation [four areas of teeth] and bleeding by lightly probing within gingival sulcus. ²
•   0= Normal gingiva
•   1= Mild inflammation, slight change in color and edema but no bleeding on probing
•   2 = Moderate inflammation, redness, edema, and bleeding on probing
•   3= Severe inflammation, redness, edema, ulceration with tendency to spontaneous bleeding

Periodontal disease can be assessed as localized and generalized periodontitis by using different methods to detect gingivitis and periodontal disease: visual, probing, radiographs, and mobility.
•   Visual: In Photo 1, you can see a varying difference between the two oral bacterial infections just from a visual standpoint of the periodontium.
o   Healthy: pink gingiva, firm, stippled, and fits snug around the teeth
o   Gingivitis: redness, swelling, and bleeding and possible tender to touch
o   Periodontitis: possible same signs and symptoms as gingivitis with bone loss, perio pocketing, loss of periodontal ligament attachment, and mobility as it progresses
•   Probing Depths ³:
o   The Community Periodontal Index [CPI] or Periodontal Screening & Recording [PSR] Probe is an ideal probe [with the 0.5 mm ball on the end] to determine the sextant screening code [0, 1, 2, 3, or 4] to establish if a patient needs a full mouth probing depth based on the scores. If using a probe does not have a ball tip or black band to indicate 3.5mm to 5.5mm, you must modify for periodontal probing accordingly:
o   Use the millimeter markings of your probe to approximate the CPITN cut-offs.
o   <3.5 mm ? equivalent to “healthy/gingivitis” [Codes 0–2].
o   4–5 mm ? Code 3.
o   ?6 mm ? Code 4.

Photo 2
CPI/PRS Probe UNC Full-mouth Probe




Periodontal Screening & Recording


?   Code 0 – healthy gingiva, no bleeding, no calculus; colored band completely visible, ? 3.5mm

?   Code 1 – bleeding with no calculus present; colored band completely visible, ? 3.5mm

?   Code 2 – calculus present, possible bleeding; colored band completely visible, ? 3.5mm

?   Code 3 – bleeding and calculus may or may not be present; colored band partial visible, ? 3.5mm and < 5.5mm

?   Code 4 – bleeding and calculus may or may not be present; colored band not visible, ? 5.5mm; needs full mouth periodontal examination


1.   The UNC Full-mouth Periodontal Probe [below] is one type of probe used to measure the six areas of each tooth [below] to determine deepest pocket depth and is recorded for periodontal therapy.
UNC Full-mouth Periodontal Probe: Six areas of each tooth


•   Radiographs: In the photo below, you can see bone loss with supragingival and subgingival calculus. The prickly attachments to the teeth depict where calculus is located within the oral cavity.


•   Mobility: utilizing two metal handles of dental instrument handles to move teeth buccolingual to classify severity of mobility.

Mobility Grading System: Miller Index [one of most common] ?
0 – Normal; physiologic mobility
1 – Greater than normal [physiological]; slight mobility, minor horizontal or lateral
2 - <1 mm in buccolingual direction; moderate mobility, noticeable horizontal and vertical/axial
3 - >1 mm in buccolingual direction, depressible; severe mobility, significant horizontal and vertical

Stage and Grade Periodontal Health
Gingivitis: Because there are various GI assessment methods available to score GI, one of the most common scoring index, LoeProbe and Silness, are confined to visual assessments of the gingiva and bleeding on probing. The GI, combination of visual assessment and periodontal probing, can be classified into four stages of gingivitis²:
•   0= Normal gingiva
•   1= Mild inflammation, slight change in color and edema but no bleeding on probing
•   2 = Moderate inflammation, redness, edema, and bleeding on probing
•   3= Severe inflammation, redness, edema, ulceration with tendency to spontaneous bleeding
Periodontitis?: The newly 2018 Periodontal Classification can be utilized on new and existing patients based on information collected during patient treatment appointments. Information collected for staging and grading for each patient.

Staging: Intends to classify the severity and extent of a patient’s disease based on the measurable amount of destroyed and/or damaged tissue as a result of periodontitis and to assess the specific factors that may attribute to the complexity of long-term case management.
•   Severity: [CAL], radiographic bone loss, and tooth loss to determine the four stages of periodontitis [I, II, III, and IV]
•   Complexity: addition of local factors of probing depths, bone loss, and rehabilitation needs
•   Extent and distribution: classify as localized, generalized or molar/incisor pattern

Grading: Aims to indicate the rate of periodontitis progression, responsiveness to standard therapy, and potential impact on systemic health.
•   Primary criteria of direct or indirect progression periodontitis over of years
•   Grade modifiers identify risk factors, such as smoking and diabetes


References
Holmstrup, Palle; Plemons, Jacqueline; & Meyle, Joerg. 2018. “Non-plaque-induced gingival diseases.” Journal of Periodontology 8, 89; September 2017: S28-S45; DOI: 10.1002/JPER.17-0163
https://aap.onlinelibrary.wiley.com/doi/epdf/10.1002/JPER.17-0163

Trombelli, Leonardo; Farina, Roberto; Silva, Cleverson O.; Tatakis, Dimitris N,. 2018. “Plaque-induced gingivitis: Case definition and diagnostic considerations.” Journal of Periodontology 8:89; October 2017: S46-S73; DOI: 10.1002/JPER.17-0576
https://aap.onlinelibrary.wiley.com/doi/epdf/10.1002/JPER.17-0576

Smith, G. Todd. Revised 2024. “The Explorer.” PPT for EFDA Perio Training

Kim, Gi Youn; Kim, Sunjai; Chang, Jae-Seung; and Pyo, Se-Wook. 2024. “Advancements in Methods of Classification and Measurement Used to Assess Tooth Mobility: A Narrative Review.” Journal of Clinical Medicine 13, 142.12pp; doi.org/10.3390/jcm13010142 https://pmc.ncbi.nlm.nih.gov/articles/PMC10779763/pdf/jcm-13-00142.pdf

American Academy of Periodontology.perio.org/2017wwdc
https://www.perio.org/wp-content/uploads/2019/08/Staging-and-Grading-Periodontitis.pdf

Additional References:
Community Periodontal Index [CPI] Guide for IHS, Tribal, and Urban Dental Programs
file:///U:/EFDA20Perio20Course20Informaton/Protocol20-20IHS20Community20Periodontal20Index20[CPI]20Guide.pdf

Required Reading:
https://pubmed.ncbi.nlm.nih.gov/29926945/

https://pubmed.ncbi.nlm.nih.gov/29926492/

https://pubmed.ncbi.nlm.nih.gov/38202149/

https://www.perio.org/wp-content/uploads/2019/08/Staging-and-Grading-Periodontitis.pdf

https://www.ihs.gov/doh/documents/perio/Protocol20-20IHS20Community20Periodontal20Index20[CPI]20Guide.pdf

1]   Know what periodontal conditions are reversible and which are not.
2]   Understand periodontal coding
3]   Know the four methods of detecting periodontal disease

The speaker has no conflicts of interest to report.

It is the policy of the Indian Health Service, Division of Oral Health, that faculty/planners disclose any financial or other relationships with commercial companies whose products may be discussed in the educational activity. The Indian Health Service, Division of Oral Health, also requires that faculty disclose any unlabeled or investigative use of pharmaceutical products and medical devices. Images that have been falsified or manipulated to misrepresent treatment outcomes are prohibited.

None of the faculty/planners for this activity has a conflict of interest, and there is no use of unlabeled or investigative pharmaceutical products or medical devices. No images have been falsified or manipulated to misrepresent treatment outcomes.The educational objectives, content, and selection of educational methods and instructors are conducted independent of any commercial entity.

The IHS Division of Oral Health is an accredited sponsor of continuing education under the American Dental Association Continuing Education Recognition Program (CERP). ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the IHS at IHS CDE Coordinator or to the Commission for Continuing Education Provider Recognition at CCEPR.ada.org

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