Clinical diagnosis advancements in periodontics

ADVANCES IN CLINICAL DIAGNOSIS
PRESENTER- DR.TANYA ATTRE
DEPARTMENT OF PERIODONTOLOGY
& ORAL IMPLANTOLOGY

Contents
INTRODUCTION DIAGNOSIS, NEED OF DIAGNOSIS, CONVENTIONAL CLASSIFICATION, LIMITATIONS,
ADVANCE DIAGNOSTIC AIDS
PERIODONTAL PROBES GENERATIONS OF PERIODONTAL PROBES
ADVANCES IN OCLUSAL
ANALYSIS
T-SCAN
ORAL MALODOUR GAS CHROMATOGRAPHY, PORTABLE VOLATILE SULPHUR COMPOUND, ELECTRONIC NOSE,
TONGUE SULFIDE PROBE, DIAMOND PROBE
CALCULUS DETECTOR FIBEROPTIC ENDOSCOPY, FLUORESENCE, SPECTRO-OPTICAL TECHNOLOGY
GINGIVAL TEMP TOOTH MOBILITY & AI IN PERIODONTOLOGY

INTRODUCTION
“Diagnosis is not the end, but
the beginning of practice”-
Martin H Fischer
• Periodontal diseases are prevalent human diseases defined by the signs and
symptoms of gingival inflammation and periodontal tissue destruction. These
diseases are conventionally diagnosed by clinical evaluation of the signs of
inflammation in the gingiva without periodontal tissue destruction (gingivitis) or
by the presence of both inflammation and tissue destruction (periodontitis)
• The traditional clinical diagnosis is made by measuring either the loss of
connective tissue attachment to the root surface (clinical attachment loss) or the
loss of alveolar bone (radiographic hone loss)
Ko TJ, Byrd KM, Kim SA. The Chairside Periodontal Diagnostic Toolkit: Past, Present, and Future. Diagnostics (Basel). 2021 May 22;11(6):932.

DIAGNOSIS
Art of distinguishing one disease from another and determination
of nature, location and causes of a disease.
Periodontal diagnosis
“Recognizing a departure from normal in the periodontium and
distinguishing one disease from another. It must be based on
compilation of information from the medical and dental history,
from signs and symptoms of disease and from clinical and
radiographic examination of the patient.”
Ko TJ, Byrd KM, Kim SA. The Chairside Periodontal Diagnostic Toolkit: Past, Present, and Future. Diagnostics (Basel). 2021 May 22;11(6):932

Need of periodontal diagnosis
●Diagnosis of specific periodontal diseases.
●Identification of sites or subjects at an increased risk of
experiencing the progression of periodontal destruction.
●Treatment planning
●Monitoring of therapy.

● Clinical diagnosis- Bleeding on probing
Pocket depth
Attachment level measurements
● Radiographic diagnosis- IOPA
Bitewing
Panoramic radiography
● Microbiological diagnosis – Culturing
CONVENTIONAL DIAGNOSIS METHOD
Ko TJ, Byrd KM, Kim SA. The Chairside Periodontal Diagnostic Toolkit: Past, Present, and Future. Diagnostics (Basel). 2021 May 22;11(6):932

Advancement in Clinical Diagnosis
Periodontal
Probing
Occlusal analysis
Tooth mobiIity
Oral malodor
Calculus
Detection
Gingival
Temperature

PERIODONTAL PROBES
• The word probe is derived from the Latin word probo, which means “to
test.”
• Periodontal probes are used primarily to detect and measure periodontal
pockets and clinical attachment loss.
• In addition, they are used to locate calculus; measure gingival
recession, width of attached gingiva, and size of intraoral lesions; identify
tooth and soft-tissue anomalies; locate and measure furcation
involvements; and determine mucogingival relationships and bleeding
tendencies.
• However, periodontal probing has its limitations
Ramachandra SS, Mehta DS, Sandesh N, Baliga V, Amarnath J. Periodontal probing systems: a review of available
equipment. Compend Contin Educ Dent. 2011 Mar;32(2):71-7.

● 1882 -John W Riggs first described the periodontal
probe as a tool in the diagnosis of periodontal
disease.
● In 1925- F.V. Simmonton stated that “the only way
to determine the existence and extent of pyorrhea
was by the measurement of pockets”. He described
the periodontal probe and its uses
● In 1958- Orban described the periodontal probe as
the ”eye of the operator beneath the gingival margin.
HISTORY OF PERIODONTAL PROBES
Ramachandra SS, Mehta DS, Sandesh N, Baliga V, Amarnath J. Periodontal probing systems: a
review of available equipment. Compend Contin Educ Dent. 2011 Mar;32(2):71-7.

• Hanford and Patten’s design of a periodontal probe then called
a periodontometer and made of silver is nearly same in
appearance as the probes that are routinely used in clinical
practice today.
• In1992, B.L.Philstrom created a classification of periodontal
probes which included 3 generations and
• In 2000, Watts included fourth and fifth generations.
Ramachandra SS, Mehta DS, Sandesh N, Baliga V, Amarnath J. Periodontal probing
systems: a review of available equipment. Compend Contin Educ Dent. 2011 Mar;32(2):71-7.

1. Periodontal probes suitable for a general dental practice:
a. First generation
b. Second generation
2. Periodontal probes suitable for a dental practice with an
interest in periodontics:
a. First generation
c. Third generation (if computerization is adequate)
3. Periodontal probes suitable for a specialty periodontal
practice and university and research institutions:
a. First generation
c. Third generation
d. Fifth generation
RECENT CLASSIFICATION BASED ON PERIODONTAL PROBE
SELECTION
Ramachandra SS, Mehta DS, Sandesh N, Baliga V,
Amarnath J. Periodontal probing systems: a review
of available equipment. Compend Contin Educ
Dent. 2011 Mar;32(2):71-7.

● These are conventional and
manual/hand-held probes made up
of stainless steel or plastic.
● They are not attached with any
pressure or force measuring device.
● The working ends are round,
tapered, flat or rectangular with
smooth rounded end.
1ST
GENERATION PROBE
Periodontal Probe: A review; Dr. Sohini Banarjee, Prof. Dr. Abhijit Chakroborty, Prof. Dr. T.
K. Paul. (JIDA, WB Vol 29 , No 2 , July 2013

UNC-15 PROBE GOLDMAN FOX
PROBE
WHO PROBE WILLIAM PROBE

FIRST GENERATION PROBE
● Williams probe has markings at 1, 2, 3, 5, 7, 8, 9, and 10 mm.
● Marquis probe or Hu-friedy color coded probe is color coded by
alternately colored or black and silver bands that mark 3, 6, 9, and 12
mm.
● Michigan O probe with Williams markings has circumferential lines at
1 mm, 2 mm, 3 mm, 5 mm, 7 mm, 8 mm, 9 mm, and 10 mm.
● PCP12 probe with Marquis markings has alternating shades every 3
mm.
● CPITN probe has markings at 3.5, 5.5, 8.5, and 11.5mm.

PERIODONTAL PROBE
GENERATIONS
First Generation
(Conventional)

● Metal probes, which are standard in traditional periodontal probing,
pose a risk of microabrasion to the titanium surface of implants.
Such abrasions can increase surface roughness, creating niches for
bacterial colonization and potentially leading to peri-implant
diseases.
● In contrast, non-metallic probes, particularly those made of carbon
or plastic, are less likely to cause such damage due to their softer and
less abrasive nature.
● These probes are recommended to reduce the risk of
implant surface modification.
PLASTIC COLORVUE PROBE
Ramachandra SS, Mehta DS, Sandesh N, Baliga V, Amarnath J.
Periodontal probing systems: a review of available equipment. Compend
Contin Educ Dent. 2011 Mar;32(2):71-7.

SECOND GENERATION
●Second generation probe are pressure sensitive
●To improve standardization of controlled probing
pressure. Weinberg et. al. Stated that, Controlled force of
20-25 gms during probing, reduce examiner error &
made depth changes of less than 2 mm which was
clinically meaningful
●Pressure should not exceed 0.2 N/mm2
SS, Ramachandra & Mehta, Dhoom & Sandesh, Nagarajappa & Baliga, Vidya & Amarnath, Janardhan. (2011). Periodontal probing
systems: A review of available equipment. Compendium of continuing education in dentistry (Jamesburg, N.J. : 1995). 32. 71-7.

True Pressure Sensitive
(TPS) probe Vine valley Probe
YEAPLE PROBE

MATERIAL & METHOD The investigation was performed on 57 patients,
each of them subjected to both conventional and electronic probing. The
tolerance degree for each probing type and also the time
consumed with probing and periodontal charting were recorded.
RESULT-
Periodontal probing with an electronic probe gave better results as to the
accuracy of measurements, tolerance level and time consumed,
appearing as an exceptionally precise method in establishing the
diagnosis, as well as in assessing the treatment results.

THIRD GENERATION
• Probes with controlled probing force that are capable of automated
computerized data recording
• Probes available:
Florida probe
Toronto probe
Foster-miller probe
Interprobe

Foster Miller probe
Florida probe
SS, Ramachandra & Mehta, Dhoom & Sandesh, Nagarajappa & Baliga, Vidya & Amarnath, Janardhan. (2011). Periodontal probing
systems: A review of available equipment. Compendium of continuing education in dentistry (Jamesburg, N.J. : 1995). 32. 71-7.

Ultrasonographic probe (4th
generation)
Described by Orban as the ‘the eyes of the operator beneath the gingival margin’, periodont, 8.. Simonton
(1925)9
and Box (1928)10
were among the first to advocate the routine use of calibrated probes to measure
and document the extent of detachment of periodontal tissues from root surfaces11
. Pihlstrom (1992)
classified probes into three generations12
. In 2000, Watts extended this classification by adding fourth- and
fifth-generation probes13
.
These are three dimensional probes.
These probes help in measuring the sequential probe
positions along gingival sulcus.
Its goal is to obtain a precise and continuous reading
of the base of the sulcus or pocket.
The 3d visualization provides quite accurate
information about the periodontal pocket.
These probes are currently under development.
4TH
GENERATION PROBE

● Probes are being designed to be 3D and noninvasive: an
ultrasound or other device is added to a fourth-generation
probe
● Fifth-generation probes aim to identify the attachment
level without penetrating it.
FIFTH GENERATION PROBE

ULTRASONOGRAPHIC PROBE
The probe is designed to have a
removable tip, space for a 2-mm
active area transducer housed at
the base of this tip, a water line
input that runs through the probe
handle and empties into a small
open area around the transducer,
and an electronics input–output
cable that also runs through the
base and is connected to the
transducer.
SS, Ramachandra & Mehta, Dhoom & Sandesh, Nagarajappa & Baliga, Vidya & Amarnath, Janardhan. (2011).
Periodontal probing systems: A review of available equipment. Compendium of continuing education in dentistry
(Jamesburg, N.J. : 1995). 32. 71-7.

● Articulating paper foils and ribbons have been used
extensively in clinical practice as occlusal indicators.
● Research on articulating paper mark size has revealed that
the size of an articulating paper mark does not describe
occlusal forces- Carey et al (2007)
● As an alternative method to the operator’s subjective
interpretation of articulating mark appearance,
computerized occlusal analysis is available to the
practitioner
ADVANCES IN OCCLUSAL ANALYSIS
Arihant Bathiya, Sweta Kale Pisulkar. Digital occlusal analysis using T scan: Its role, mechanism,
accuracy and application. Medical Science, 2020, 24(105), 2826-2834

PARTS OF T-SCAN

APPLICATION
● Occlusal Corrections after definitive rehabilitation
● Implant dentistry: Occlusal overloading being the proven
factor for implants complications. It is very cumbersome
task to identify overloading contact by articulating paper,
sometime it not achieved with accuracy. Occlusal
overloading can be identified by T scan (Pyakurel et al.,
2013), (Sidana et al., 2013) and (Garg, 2007). Implant
occlusion can be successfully managed using T scan (Dario,
1995) and (Luo et al., 2019).
● Diagnostic screening
● Orthodontic treatment
● Temporomandibular joint

● In 2006, a USB plug-in recording handle and new generation of
software were released as the t-scan occlusal analysis system.
● The system displays a recorded occlusal “force movie,” which
illustrates the various occlusal pressures with colors during playback.
The darker colors represent low occlusal pressures and the brighter
colors indicate higher occlusal pressures.
● The t-scan system is a valuable tool that aids in the diagnostic process
of analyzing a patient’s bite to show what is and what is not functioning
properly.
T-SCAN

 3-dimensional dental patient is assembled from the data
scanned from the casts of a patient’s dentition.
 This provides quantitative information that would aid in
the assessment of his chewing function and in identifying
the occlusal interferences.
 Further, the sequential comparison of these occlusal
contacts enables the dentist to identify the changes in the
patient’s occlusion as time elapses.

● Major compounds that contribute to oral malodor are
volatile sulfur compounds such as hydrogen sulfide ,
methyl mercaptan and dimethyl sulfide.
● Additionally, propionic acid and butyric acid,
cadaverine, indole, and scatole, have been reported to
cause oral malodor which results from the proteolytic
degradation by predominantly anaerobic Gram negative
microorganisms associated with gingivitis and/or
periodontitis
HALITOSIS

GAS CHROMATOGRAPHY
Gas chromatography (GC) with flame
ionization detection has been applied to
measure oral malodor. A number of volatile
components have been identified by GC.
Gas Chromatography equipped with a indium
oxide semiconductor gas sensor (SCS), which
is highly sensitive to all kinds of VSC's has been
developed recently. It measures each VSC's
separately, whereas other devices cannot detect
each separately.

PORTABLE VOLATILE SULFUR MONITOR

FITSCAN® Breath Checker which
is an innovative palmsize monitor
that detects and measures the
presence of breath odors (VSCs).
It measures odor in seconds and
results are displayed similar to
organoleptic method.

● An artificial nose that has the same
capacities as the human nose would be
ideal. Originally these devices have been
developed for quantitative assessments of
smells in food or beverages. However, an
application to diagnosis of halitosis appears
reasonable.
● Preliminary data indicates that this device has a
potential to be used as a diagnostic tool to
detect odors.
ELECTRONIC NOSE

CALCULUS DETECTION
Meissner G, Kocher T. Calculus-detection technologies and their clinical application. Periodontol 2000.
2011 Feb;55(1):189-204.

● Current technologies for calculus identification include;
1. detection-only systems (a miniaturized endoscope)
2. device based on light reflection
3. laser that activates the tooth surface to fluoresce) as well
as combined calculus-detection and calculus-removal
systems [an ultrasonic oscillation based system that
analyzes impulses reflected from the tooth surface, and a
system combining erbiumdoped yttrium aluminium garnet
(Er:YAG) and diode lasers]
2011 Feb;55(1):189-204.

2011 Feb;55(1):189-204.

Geisinger ML, Mealey BL, Schoolfield J, Mellonig JT. The effectiveness of subgingival scaling and root planing:
an evaluation of therapy with and without the use of the periodontal endoscope. J Periodontol 2007: 78: 22–28

GINGIVAL
TEMPERATURE
Rams, T. E., Slots, J. (2024). Elevated subgingival temperature infers high bacterial pathogen counts in severe
periodontitis. Clinical and Experimental Dental Research, 10, e891

● An electronic temperature probe (PerioTemp
Probe System, ABIODENT Inc.) measured
absolute subgingival and sublingual site
temperatures and determined normalized
differential values of subgingival temperature
relative to sublingual temperature.
TEMPERATURE SENSITIVE PROBE

PERIO-TEMP PROBE
The temperature probe
designated the
subgingival temperature
as either “hot” (red
light) or “cool” (green
light)

STUDY BY RAM & SLOT -
Hot periodontal pockets had an
average depth of 7.9 ± 1.3 (SD) mm
(range 6 10 mm) per patient, and cool
‒
periodontal pockets an average depth
of 7.5 mm ± 1.3 (SD) (range 6 10
‒
mm)
Hot periodontal pockets per
patient showed
significantly higher
temperatures (averaging
37.03°C, range 36.38–
38.31°C) than cool
periodontal pockets
(averaging 36.58°C, range
34.34–38.0°C) (p = 0.031).

Hot periodontal sites with elevated levels of P. gingivalis, P.
intermedia/nigrescens, P. micra, and
A.actinomycetemcomitans and cool periodontal sites with
health related Capnocytophaga species and viridans
‐
streptococci (Haffajee et al., 1992c; Rams & Slots, 2023).
High subgingival temperatures may indicate an increased risk for
periodontal breakdown (Haffajee et al., & Lindskog et al.).
Hot periodontal sites were more than twice as likely as cool
periodontal sites to experience progressive periodontitis
(Haffajee et al.,).
whereas shallow pockets with cool temperature and bleeding on
probing demonstrated progressive attachment loss in only 1.4%
of sites (Haffajee et al.,)

● Socransky and Haffajee 1994 Suggested that
Endotoxins of infecting bacteria, especially
lipopolysaccharides (IPS) from Gram-negative
organisms are exogenous pyrogens that stimulate
macrophages to release endogenous pyrogens,
producing fever Bacteria respond to changes in
environmental temperature.
STUDIES

TOOTH MOBILITY
Kim GY, Kim S, Chang JS, Pyo SW. Advancements in Methods of Classification and Measurement Used to
Assess Tooth Mobility: A Narrative Review. J Clin Med. 2023 Dec 27;13(1):142.

● Tooth mobility refers to how loose a tooth is from the
alveolar socket.
● The factors that influence tooth mobility include the height
of the supporting alveolar bone, the width of the
periodontal ligament, the presence of inflammation, the
shape of the root(s), and the number of roots
● The evaluation is performed by placing the handles of the
dental instruments on either side of the tooth’s mesiodistal
axis and applying moderate pressure alternately, assessing
the handle of the other instrument . Vertical tooth mobility
refers to the degree to which the tooth can move
downward within the alveolar socket.
TOOTH MOBILITY

● In the early stages of device development, a static
loading method was utilized to measure tooth mobility.
However, this method is subjective, has low
reproducibility, and presents challenges in achieving
precise numerical measurements
● Subsequently, a dynamic loading method was developed
to measure tooth mobility. This method enabled the
accurate measurement and quantification of tooth
mobility
TOOTH MOBILITY

DEVICES
DISPLACEMENT MEASURING DEVICE
STRAIN MEASURING DEVICES
MODEL MEASURING DEVICES
1.
3.
2.

Displacement Measuring Devices
Konermann, A.; Al-Malat, R.; Skupin, J.; Keilig, L.; Dirk, C.; Karanis, R.; Bourauel, C.; Jäger, A. In vivo
determination of tooth mobility after fixed orthodontic appliance therapy with a novel intraoral

Methods
Three experienced periodontists were asked to push tooth #16 into a buccal position to in a
typodont model with different mobility (M1−M2). Tooth position was obtained using an intraoral
scanner and files were compared in metrology software. Mobility was calculated at three
reference points at the cervical (C), middle (M), and occlusal (O) regions of the buccal surface of
the tooth to determine the linear deviation in the three axes (x, y, and z). Reliability was
determined by intraclass-correlation coefficient, differences between M1 and M2 determined
by t test, and the analysis of variance (ANOVA) was used to compare the data at the C-M-O
regions.
Conclusion
A novel technique to assess tooth mobility based on intraoral scanner measurements provided
reliable data in an in vitro experiment.
Meirelles, L.; Siqueira, R.; Garaicoa-Pazmino, C.; Yu, S.H.; Chan, H.L.; Wang, H.L. Quantitative tooth mobility
evaluation based on intraoral scanner measurements. J. Periodontol. 2020, 91, 202–208

Strain-Measuring Devices Picton’s Gauge
● Strain-Measuring Devices uses resistance wire strain
gauges to measure tooth mobility.
● Strain gauges detect the vertical movement of teeth,
measuring displacement or mobility.
● One end of the gauge is attached to a single tooth, while
the other end is connected to adjacent teeth through a
spring.
● The displacement of the test tooth relative to adjacent
teeth is detected by two strain gauges.
● The measurement of each tooth requires the insertion of a
custom assembly. Using these custom assemblies, tooth
stress and displacement are measured, and this
information is recorded through a Wheatstone bridge
circuit.

● Modal Measuring Devices Modal analysis has
emerged as the predominant approach within
electronic devices employed for assessing tooth
mobility.
Modal Measuring Devices

1. Developed by Meredith and his co workers 20 years back.
2. This method evaluates the stiffness of the bone-implant
interface by means of a signal transducer connected to a
frequency response analyzer (Osstell; integration diagnostics,
göteborg, sweden).
3. Osstell displays the peak of a frequency-amplitude plot.
4. Resonance frequency of the transducer-implant unit is
calculated.
5. Implant stability quotient (ISQ) is displayed as a number
between 1 and 100
RESONANCE FREQUENCY ANALYSIS

● AI (Artificial Intelligence) and ML (Machine Learning) can
significantly contribute to the field of periodontics by
enhancing diagnosis, treatment planning, and patient
outcomes. Here's how AI/ML can help in periodontics:
● Early Detection and Diagnosis
● Personalized Treatment Planning
● Enhanced Decision Support
● Monitoring and Follow-Up
● Educational Tools for Patients
and Dentists
AI IN PERIODONTAL DIAGNOSIS
Pitchika V, Büttner M, Schwendicke F. Artificial intelligence and personalized diagnostics in
periodontology: A narrative review. Periodontology 2000. 2024;95:220-231

These advances are reshaping the landscape of periodontal
diagnosis, offering more accurate, efficient, and patient-
centered care, which ultimately improves outcomes and
enhances overall oral health.
CONCLUSION

● Ko TJ, Byrd KM, Kim SA. The Chairside Periodontal Diagnostic Toolkit: Past,
Present, and Future. Diagnostics (Basel). 2021 May 22;11(6):932
● Ramachandra SS, Mehta DS, Sandesh N, Baliga V, Amarnath J. Periodontal
probing systems: a review of available equipment. Compend Contin Educ
Dent. 2011 Mar;32(2):71-7
● Periodontal Probe: A review; Dr. Sohini Banarjee, Prof. Dr. Abhijit
Chakroborty, Prof. Dr. T.K. Paul. (JIDA, WB Vol 29 , No 2 , July 2013
● Meissner G, Kocher T. Calculus-detection technologies and their clinical
application. Periodontol 2000. 2011 Feb;55(1):189-204.
● Rams, T. E., Slots, J. (2024). Elevated subgingival temperature infers high
bacterial pathogen counts in severe periodontitis. Clinical and
Experimental Dental Research, 10, e891
REFERENCES

● Konermann, A.; Al-Malat, R.; Skupin, J.; Keilig, L.; Dirk, C.; Karanis, R.;
Bourauel, C.; Jäger, A. In vivo determination of tooth mobility after fixed
orthodontic appliance therapy with a novel intraoral measurement device. Clin.
Oral Investig. 2017, 21, 1283–1289
● Geisinger ML, Mealey BL, Schoolfield J, Mellonig JT. The effectiveness of
subgingival scaling and root planing: an evaluation of therapy with and without
the use of the periodontal endoscope. J Periodontol 2007: 78: 22–28
● kasaj A, Moschos I, Rohrig B, Willershausen B. The effectiveness of a novel
optical probe in subgingival calculus detection. Int J Dent Hyg 2008: 6: 143–
147.
● Arihant Bathiya, Sweta Kale Pisulkar. Digital occlusal analysis using T scan:
Its role, mechanism, accuracy and application. Medical Science, 2020, 24(105),
2826-2834

● Meirelles, L.; Siqueira, R.; Garaicoa-Pazmino, C.; Yu, S.H.; Chan,
H.L.; Wang, H.L. Quantitative tooth mobility evaluation based on
intraoral scanner measurements. J. Periodontol. 2020, 91, 202–
208
● Kim GY, Kim S, Chang JS, Pyo SW. Advancements in Methods of
Classification and Measurement Used to Assess Tooth Mobility: A
Narrative Review. J Clin Med. 2023 Dec 27;13(1):142.

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