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ADVANCED DIAGNOSTIC AIDS
CONTENTS
 Introduction
 Efficacy of diagnostic test
 Limitations of conventional methods
 Advances in Clinical diagnosis
 Advances in Radiographic assessment
 Advances in microbiologic analysis
 Advances in charaterizing the host response
 New innovations
 Conclusion
 References
INTRODUCTION
 Proper diagnosis  Intelligent treatment
 Diagnosis Involves
 Analysis of case history
 Evaluation of clinical signs and symptoms
 Results of tests (Probing, Mobility, Radiograph, blood test,
biopsies)
 Diagnosis Determines
 Presence of disease
 Type of disease
 Underlying disease process
 A “Diagnostic” refers to tools, procedures or technologies that are
used in determination of diagnosis
 used to:
a) predisposing risk factors
b) identify early disease
c) specific type of disease
Kornman,2005
EFFICACY OF DIAGNOSTIC TEST
1. Gold standard
2. Accuracy
3. Sensitivity
4. Specificity
5. Positive predictive value
6. Negative predictive value
CONVENTIONAL CLINICAL DIAGNOSTIC TOOLS
LIMITATIONS
 Sites with ongoing periodontal destruction
 Cause
 Patient’s susceptibility to disease
whether disease is progressing??
remission??
response to periodontal therapy + /- ??
ADVANCES IN CLINICAL DIAGNOSIS
ADVANCES IN CLINICAL DIAGNOSIS
 Periodontal probes
 Non-Periodontal probes
- Calculus detection system
- Periodontal Disease Evaluation System
- Gingival Temperature
- Tooth mobility
PERIODONTAL PROBES
 Orban as the “eye of the operator beneath the gingival margin”
 Latin word “Probo”, which means “to test”.
 Gold standard
 Simonton (1925) and Box (1928) were among the first to
advocate the routine use of calibrated probes
 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.
TYPES OF PROBE:
 Pihlstrom (1992) classified probes into three generations.
 In 2000, Watts extended this classification by adding fourth-
and fifth-generation probes.
 First-Generation (Conventional) Probes:
 conventional hand-held instruments.
 Probes do not control for probing pressure and are not suited for
automatic data collection.
1. Willams’ Periodontal probe: 1936, Charles H.M. Williams
 Prototype/benchmark
2. Community Periodontal Index of Treatment Need (CPITN):
 Professor George S. Beagrie & Jukka Ainamo 1978
 FDI World Dental Federation/WHO Joint Working Group
 CPITN-E (epidemiologic) 3.5mm & 5.5mm
 CPITN-C (clinical) 3.5mm,5.5mm,8.5mm & 11.5mm
 5gm wt, ball tip 0.5 mm
3. University of Michigan O probe:
 3mm, 6mm & 8mm
4. University of North Carolina-15 (UNC-15):
5. Naber’s probe:
 Furcal areas
advanced diagnostic aids in periodontics
 Second-Generation (Constant-Pressure) Probes:
 Pressure sensitive , not exceed 0.2 N/mm2 (Waerhaug, 1952)
 True Pressure Sensitive (TPS) probe:
 Prototype , Hunter 1994
 Disposable probing head
 20 gm & 0.5mm dia
 First true pressure-sensitive periodontal probe :
 Gabathuler and Hassell (1971)
 periodontal probe & a small piezoelectric pressure sensor which
was attached to the non-probing end of the probe tip.
 In 1977, Armitage : Simple pressure-sensitive periodontal probe
holder :
 To standardize the insertion pressure.
 In 1978, van der Velden presented the "Pressure Probe", which
allowed probing force to be adjusted.
 Cylinder & a Piston connected to a variable air pressure system
 The electronic pressure-sensitive probe, allowing for control of
insertion pressure, was introduced by Polson in 1980.
 Polson’s original design was modified: the probe is known as the
Yeaple probe, which is used in studies of dentinal
hypersensitivity (Kleinberg et al., 1994).
 A simple, constant-force, periodontal probe was presented by
Borsboom and co-workers (1981). Their instrument used a
stainless steel spring to generate constant force.
 Kalkwarf et al 1986:
 force upto 30 g Junctional epithelium
50 g periodontal osseous defects
 Third-Generation (Automated) Probes:
 Controlled force application, automated measurement and
computerized data capture and storage
 Foster-Miller probe (Foster-Miller Inc, Waltham, MA): prototype.
 Jeffcoat et al. in 1986,
 capable of automated cemento-enamel junction (CEJ) detection
and direct measurement of attachment level with a high level of
repeatability and accuracy.
 National Institute for Dental and Craniofacial Research (NIDCR):
 Gibbs et al. (1988) developed the Florida Probe® system (Florida
Probe Corp, Gainesville, FL):
 constant probing force, precise electronic measurement to 0.1
mm and computer storage of the data and sterilization of all
system parts entering or close to the mouth
 CAL- Fixed reference point
occlusal surface of teeth- disk probe
prefabricated stent- Stent probe
 Florida PASHA Probe- Modified sleeve, tip edge 0.125 mm
“catch” of the CEJ
 Birek et al. (1981) and McCulloch et al. (1981) developed the
Toronto Automated probe:
 It used the occlusal/ incisal surface to measure relative clinical
attachment levels.
 Goodson and Kondon (1988) used fiber optic technology in their
controlled-force Accutek probe.
 The InterProbe™ (The Dental Probe Inc, Glen Allen, VA), also
known as the Perio Probe, is a third-generation probe with a
flexible probe tip, Jeffcoat 1991
advanced diagnostic aids in periodontics
 Fourth generation probes:
 Three-dimensional (3D) probes. Currently under development
 Fifth-Generation Probes:
 3D and non-invasive: an ultrasound or other device is added to a
fourth-generation probe.
 aim to identify the attachment level without penetrating it.
 The only fifth-generation probe available, the Ultrasonographic
(US) probe (Visual Programs, Inc, Glen Allen, VA), uses
ultrasound waves to detect, image and map the upper boundary
of the periodontal ligament and its variation over time as an
indicator of the presence of periodontal disease.
 Hinders &Companion at the NASA Langley Research Center.
advanced diagnostic aids in periodontics
NON-PERIODONTAL PROBES
 Calculus Detection
 Based on measurements of resonance vibrations of ultrasonic
treatment or autofluorescence induced by laser irritation.
 Recently, a novel calculus detection system DetecTar (Ultradent,
Salt Lake City, UT, USA) employing spectro-optical technology
has been suggested as a potential aid in detecting subgingival
calculus
 Periodontal Disease Evaluation System
 The Diamond Probe/Perio 2000 System® is a dental device
designed to detect sulphide concentrations of various forms (S,
HS, H2S and CH3SH) in gingival sulci
 The system combines a conventional Michigan “O” style dental
probe with a sulphide sensor, which measures periodontal
probing depth, bleeding on probing and sulphide levels
simultaneously
GINGIVAL TEMPERATURE
 Increased blood flow and a very high metabolic rate
 Kung et al Sensitive diagnostic devices for measuring early
inflammatory changes in the gingival tissues
 PerioTemp probe (Abiodent)= sensitivity of 0.1o C
 2 light indicating diodes:
 Red-emitting diode higher temp
 Green-emitting diode lower temp
Diseased sites
Posterior teeth
Mandibular sites
 Temp increases with probing depth = Unknown
 Haffajee et. al., 1992  sites with higher temperature have greater
than twice the risk of future attachment loss
 Pathogens
 Increased temperature
Unclear
TOOTH MOBILITY
 Periotest Probe is a hand-held probe,
 Mobility is recorded in Periotest units (PTU) from 0 to 50.
 The instrument (BioResearch, Milwaukee, Wisconsin, USA) taps
each tooth with an impeller 16 times and measures the time
taken for the tooth to return to its original position.
ADVANCES IN RADIOGRAPHIC ASSESSMENT
 Destruction of alveolar bone
 Cannot accurately reflect bone morphology= buccally/ lingually
 Interproximal bone levels
 Root length, root proximity, presence of periapical lesions,
estimates of remaining alveolar bone.
 More than 30% of bone mass lost
 Conventional radiographs are very specific but lack sensitivity
 Commonly used
 Bitewing
 Periapical
 Panoramic
 Variations in projection geometry
 Variations in contrast & density caused by differences in film
processing, voltage, & exposure time &
 Masking of osseous changes by other anatomic structures (2D
mapping of 3D structures)
ADVANCES IN RADIOGRAPHIC ASSESSMENT
 Digital radiography
 Digital subtraction radiography
 Computer-assisted densitometric image analysis system (CADIA)
 Tuned aperture computed tomography (TACT)
 Computed tomography (CT)
 Cone-beam computed tomography (CBCT)
 Local computed tomography (LCT)
 Magnetic resonance imaging (MRI)
 Nuclear medicine bone scans
 Optical coherence tomography (OCT)
 Ultrasound imaging
DIGITAL RADIOGRAPHY
 Advantages:
 The elimination of chemical processing.
 Shorter exposure-to-display time.
 1/3rd to 1/2rd of dose reduction
 Computerized images which can be stored
 Selected region in the image can be enhanced for a specific
diagnostic task.
 The software offers a variety of measurement tools
 Two digital radiography systems rely on the sensor –
 Direct method  solid-state detectors which are based either on
charge-coupled device technology (CCD) or on complementary
metal oxide semiconductor technology (CMOS)
 key features is the immediate availability of the image
 Disadv: limited x-ray sensitive surface of the sensor
thicker, rigid & cable attachment besides sterility issue.
 Indirect methods: (Digora System)
 uses a phosphor luminescence plate, which is a flexible film-like
radiation energy sensor placed intraorally and exposed to
conventional X-ray tubes.
 Adv: plate size and flexibility
plates are then erased and can be reused.
 Disadv: increased time and effort for
scanning
advanced diagnostic aids in periodontics
DIGITAL SUBTRACTION RADIOGRAPHY
 First demonstrated by Zeidses Des Plantes,1935
 Principle: current image is superimposed on the previous. Only
the areas of change appear
 positive difference  brighter
 negative difference  darker
 Baseline project geometry and image density must be reproduced
 A high degree of correlation between changes in alveolar bone
determined by SR & CAL changes in periodontal patients after
therapy
 Increased detectability of small osseous lesions.
 Disadv: identical projection alignment during sequential
radiograph
 Diagnostic subtraction radiography (DSR) positioning device +
specialized software
COMPUTER-ASSISTED DENSITOMETRIC IMAGE
ANALYSIS SYSTEM
 Video camera measures the light transmitted through a
radiograph and the signals from the camera are converted into
gray-scale images.
 higher sensitivity and a high degree of reproducibility and
accuracy.
TUNED APERTURE COMPUTED TOMOGRAPHY
(TACT)
 To assess tissues in three dimensions
 Based on the principle of tomosynthesis:
 By shifting and combining a set of basis projections, arbitrary
slices through the object can be brought into focus
 Improves detection of defects around implants
 Tyndall et al., 2002  TACT is superior to conventional
radiography in detecting pericrestal bone gain
COMPUTED TOMOGRAPHY (CT)
 In 1972, Godfrey Hounsfield
 The X-ray source travels helically around the patient many times,
emitting a narrow fan beam until the region of interest is
covered.
 The beam exiting the patient is captured in a digital sensor
 Axial, coronal or sagittal planes
 This is referred to as multiplanar reformatted imaging
 Indication for evaluating prospective implant sites for the
amount & character of remaining alveolar bone.
 Fuhrmann et. al., 1995  CT assessment of alveolar bone height
and intrabony pocket is reasonably accurate
 Dentascan:
CONE-BEAM COMPUTED TOMOGRAPHY (CBCT)
 reduced dose of radiation
 Drawbacks:
 increased effect of scatter radiation on image quality. Scatter
radiation reduces contrast and limits the imaging of soft tissues.
 CBCT is mainly indicated for imaging hard tissues.
LOCAL COMPUTED TOMOGRAPHY (LCT)
 A form of CBCT
 Uses a small field high resolution detector to generate a limited
high resolution 3D volume
 advantages of reduced patient dose and low cost
 Limited commercial availability
MAGNETIC RESONANCE IMAGING (MRI)
 Non-ionizing radiation from the radiofrequency (RF) band
 Soft tissues have a high water content, MRI provides excellent
soft tissue contrast resolution
 Adv:
 It offers the best resolution of tissues of low inherent contrast.
 No ionizing radiation is involved
 Since the region of the body imaged is controlled electronically,
direct multiplanar imaging is possible without reorienting the
patient.
 Disadv:
 expensive,
 requires considerable scan time for high resolution images
 may be claustrophobic for the patient
 the potential of causing movement of ferromagnetic metals in the
vicinity of the imaging magnet
 Metals used in dentistry for restorations or orthodontics will not
move but may distort the image in their vicinity
NUCLEAR MEDICINE BONE SCANS
 Radiolabeled pharmaceuticals that are specifically intended to
image particular organs or detect specific disease processes.
 assessing physiologic change in the absence of anatomic change.
 technetium-labeled diphosphonate called 99m-Tc-methylene
diphosphonate
 To perform a bone scan,
 the radiopharmaceutical is injected intravenously.
 Following a period to allow for bony uptake of the agent, uptake
is either imaged using a gamma camera or measured using
specially designed detectors for intraoral use.
 Areas of active bone loss appear as hot spots in the image
 Used :
 determine whether a patient has active sites of bone loss and
could benefit from an experimental treatment,
 to determine whether a patient who is to undergo a bone marrow
transplant has sites of active periodontal disease or occult disease
that need immediate attention.
OPTICAL COHERENCE TOMOGRAPHY (OCT)
 Biologic imaging system in 1991 by Huang et al
 high-resolution cross-sectional images of biologic structures by
scanning a lightly focused light beam across the tissue
 It uses broadband low-coherent Near-Infrared (NIR) light
sources
 Dental OCT images clearly depict anatomical structures that are
important in the diagnostic evaluation of both hard and soft oral
tissue
 Periodontal tissue contour, sulcular
depth and connective tissue
attachment
 Active periodontal disease before
significant alveolar bone loss
occurs.
 3D imaging of periodontal soft
tissues and bone
ULTRASOUND IMAGING
 Ultrasonics is a branch of acoustics concerned with sound
vibrations in frequency ranges above audible level.
 Ultrasound imaging, or ultrasound scanning or sonography, is a
method of obtaining images from inside the human body
through the use of high frequency sound waves.
 Non-invasive periodontal assessment tool
 1 to 20 megahertz
 Spranger (1971) who tried to determine the height of the
alveolar crest
 Adv:
 ultrasound imaging can visualize periodontal and oral tissues in
vivo or ex vivo without the need for complicated processing,
fixing or staining.
 It is fast, easy and a reproducible technique.
 non-invasive nature of the imaging
 the avoidance of ionising radiation,
ADVANCES IN MICROBIOLOGIC ANALYSIS
 Diagnostic microbiology- involves the study of specimens taken
from patients suspected of having infection
 More than 300 species isolated from different individuals
 40 species from a single site
Microbiological tests are useful..
1) To identify putative pathogens and supporting the diagnosis of
various forms of periodontal disease
2) To serve as indicators of disease initiation and progression and
healing
3) To determine which periodontal sites are at higher risk for active
destruction
4) To monitor periodontal therapy
5) To aid in treatment planning of patients with aggressive or non
responding periodontitis by helping the doctor in selection of
adjunctive antimicrobial therapy
ADVANCES IN MICROBIOLOGIC ANALYSIS
 Bacterial culturing
 Direct Microscopy-dark-field or phase-contrast microscopy
 Immunodiagnostic methods
 Enzymatic methods
 Diagnostic analysis based on Molecular Biology techniques
ADVANCES IN CHARACTERIZING THE HOST
RESPONSE
 Diagnostic tests have been developed that add measures of the
inflammatory process to conventional clinical measures.
 Information on the destructive process
 Current activity of the disease
 Rate of disease progression
 Patterns of destruction
 Extent & severity of future breakdown
 Response to therapy
 Assessment of the host response refers to the study of mediators,
by immunologic or biochemical methods, that are recognized as
part of the individual’s response to the periodontal infection
 Inflammatory mediators & products
 Host-Derived Enzymes
 Tissue Breakdown products
NEW INNOVATIONS
 Proteome analysis
 Genetic analysis
 Proteome analysis:
 Salivary proteome:
 using both two-dimensional gel electrophoresis ⁄ mass
spectrometry and ‘shotgun’ proteomics approaches
 Hu et al. (2005) identified 309 distinct proteins in human whole
saliva
 NIDCR support salivary proteome projects, 1,166 salivary
proteins
 3 key features of pathogenic processes in periodontal disease -
inflammation, collagen degradation and bone turnover.
 GCF Proteomes:
 The composition of GCF greatly varies between health and
periodontal disease.
 Bostanci et al. (2010) performed analysis of the from healthy and
periodontally diseased sites
 154 proteins of human, bacterial and viral origin were identified
in the 40 GCF samples obtained from the 10 subjects
 The proportion of bacterial, viral and yeast protein was increased
in disease compared to health
 Genetic analysis:
 The etiology of periodontal disease is multifactorial and thus
influenced by genetics (i.e. the host) and the environment
 The periodontitis susceptibility trait test (Interleukin Genetics,
Waltham, Massachusetts) is the only genetic susceptibility test for
severe periodontitis that is commercially available.
 This system works by detection of two types of IL-1 genetic
alleles, IL1A +4845 and IL1B +3954
CONCLUSION
 After all these years of intensive research, we still lack a proven
diagnostic test that has demonstrated high predictive value for
disease progression, has an impact on disease incidence &
prevalence, & is simple, safe & cost-effective….
 Future application of advanced diagnostic techniques will be of
value in documenting disease activity & treatment options.
REFERENCES
 Newman MG, Takei HH, Klokkevold PR, Carranza FA. 10th
edition. Carranza’s Clinical Periodontology. Saunders Company
2006. 579-601.
 Ramachandra SS, Mehta DS, Sandesh N, Baliga V, Amarnath J.
Periodontal Probing Systems: A Review of Available Equipment.
Dentistry India 2009; 3(3): 2-10.
 Jeffcoat MK, Wang IC, Reddy MS. Radiographic diagnosis in
periodontics. Periodontol 2000 1995; 7: 54-68.
 Bostanci N, Heywood W, Mills K, Parkar M, Nibali L, Donos N.
Application of label-free absolute quantitative proteomics in
human gingival crevicular fluid by LC/MS E (gingival
exudatome). J Proteome Res 2010; 9(5): 2191-2199.
advanced diagnostic aids in periodontics

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advanced diagnostic aids in periodontics

  • 2. CONTENTS  Introduction  Efficacy of diagnostic test  Limitations of conventional methods  Advances in Clinical diagnosis  Advances in Radiographic assessment  Advances in microbiologic analysis  Advances in charaterizing the host response  New innovations  Conclusion  References
  • 3. INTRODUCTION  Proper diagnosis  Intelligent treatment  Diagnosis Involves  Analysis of case history  Evaluation of clinical signs and symptoms  Results of tests (Probing, Mobility, Radiograph, blood test, biopsies)  Diagnosis Determines  Presence of disease  Type of disease  Underlying disease process
  • 4.  A “Diagnostic” refers to tools, procedures or technologies that are used in determination of diagnosis  used to: a) predisposing risk factors b) identify early disease c) specific type of disease Kornman,2005
  • 5. EFFICACY OF DIAGNOSTIC TEST 1. Gold standard 2. Accuracy 3. Sensitivity 4. Specificity 5. Positive predictive value 6. Negative predictive value
  • 7. LIMITATIONS  Sites with ongoing periodontal destruction  Cause  Patient’s susceptibility to disease whether disease is progressing?? remission?? response to periodontal therapy + /- ??
  • 9. ADVANCES IN CLINICAL DIAGNOSIS  Periodontal probes  Non-Periodontal probes - Calculus detection system - Periodontal Disease Evaluation System - Gingival Temperature - Tooth mobility
  • 10. PERIODONTAL PROBES  Orban as the “eye of the operator beneath the gingival margin”  Latin word “Probo”, which means “to test”.  Gold standard  Simonton (1925) and Box (1928) were among the first to advocate the routine use of calibrated probes  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.
  • 11. TYPES OF PROBE:  Pihlstrom (1992) classified probes into three generations.  In 2000, Watts extended this classification by adding fourth- and fifth-generation probes.
  • 12.  First-Generation (Conventional) Probes:  conventional hand-held instruments.  Probes do not control for probing pressure and are not suited for automatic data collection. 1. Willams’ Periodontal probe: 1936, Charles H.M. Williams  Prototype/benchmark
  • 13. 2. Community Periodontal Index of Treatment Need (CPITN):  Professor George S. Beagrie & Jukka Ainamo 1978  FDI World Dental Federation/WHO Joint Working Group  CPITN-E (epidemiologic) 3.5mm & 5.5mm  CPITN-C (clinical) 3.5mm,5.5mm,8.5mm & 11.5mm  5gm wt, ball tip 0.5 mm
  • 14. 3. University of Michigan O probe:  3mm, 6mm & 8mm 4. University of North Carolina-15 (UNC-15): 5. Naber’s probe:  Furcal areas
  • 16.  Second-Generation (Constant-Pressure) Probes:  Pressure sensitive , not exceed 0.2 N/mm2 (Waerhaug, 1952)  True Pressure Sensitive (TPS) probe:  Prototype , Hunter 1994  Disposable probing head  20 gm & 0.5mm dia
  • 17.  First true pressure-sensitive periodontal probe :  Gabathuler and Hassell (1971)  periodontal probe & a small piezoelectric pressure sensor which was attached to the non-probing end of the probe tip.
  • 18.  In 1977, Armitage : Simple pressure-sensitive periodontal probe holder :  To standardize the insertion pressure.  In 1978, van der Velden presented the "Pressure Probe", which allowed probing force to be adjusted.  Cylinder & a Piston connected to a variable air pressure system
  • 19.  The electronic pressure-sensitive probe, allowing for control of insertion pressure, was introduced by Polson in 1980.  Polson’s original design was modified: the probe is known as the Yeaple probe, which is used in studies of dentinal hypersensitivity (Kleinberg et al., 1994).  A simple, constant-force, periodontal probe was presented by Borsboom and co-workers (1981). Their instrument used a stainless steel spring to generate constant force.
  • 20.  Kalkwarf et al 1986:  force upto 30 g Junctional epithelium 50 g periodontal osseous defects
  • 21.  Third-Generation (Automated) Probes:  Controlled force application, automated measurement and computerized data capture and storage  Foster-Miller probe (Foster-Miller Inc, Waltham, MA): prototype.  Jeffcoat et al. in 1986,  capable of automated cemento-enamel junction (CEJ) detection and direct measurement of attachment level with a high level of repeatability and accuracy.
  • 22.  National Institute for Dental and Craniofacial Research (NIDCR):
  • 23.  Gibbs et al. (1988) developed the Florida Probe® system (Florida Probe Corp, Gainesville, FL):  constant probing force, precise electronic measurement to 0.1 mm and computer storage of the data and sterilization of all system parts entering or close to the mouth
  • 24.  CAL- Fixed reference point occlusal surface of teeth- disk probe prefabricated stent- Stent probe  Florida PASHA Probe- Modified sleeve, tip edge 0.125 mm “catch” of the CEJ
  • 25.  Birek et al. (1981) and McCulloch et al. (1981) developed the Toronto Automated probe:  It used the occlusal/ incisal surface to measure relative clinical attachment levels.  Goodson and Kondon (1988) used fiber optic technology in their controlled-force Accutek probe.  The InterProbe™ (The Dental Probe Inc, Glen Allen, VA), also known as the Perio Probe, is a third-generation probe with a flexible probe tip, Jeffcoat 1991
  • 27.  Fourth generation probes:  Three-dimensional (3D) probes. Currently under development
  • 28.  Fifth-Generation Probes:  3D and non-invasive: an ultrasound or other device is added to a fourth-generation probe.  aim to identify the attachment level without penetrating it.  The only fifth-generation probe available, the Ultrasonographic (US) probe (Visual Programs, Inc, Glen Allen, VA), uses ultrasound waves to detect, image and map the upper boundary of the periodontal ligament and its variation over time as an indicator of the presence of periodontal disease.  Hinders &Companion at the NASA Langley Research Center.
  • 30. NON-PERIODONTAL PROBES  Calculus Detection  Based on measurements of resonance vibrations of ultrasonic treatment or autofluorescence induced by laser irritation.  Recently, a novel calculus detection system DetecTar (Ultradent, Salt Lake City, UT, USA) employing spectro-optical technology has been suggested as a potential aid in detecting subgingival calculus
  • 31.  Periodontal Disease Evaluation System  The Diamond Probe/Perio 2000 System® is a dental device designed to detect sulphide concentrations of various forms (S, HS, H2S and CH3SH) in gingival sulci  The system combines a conventional Michigan “O” style dental probe with a sulphide sensor, which measures periodontal probing depth, bleeding on probing and sulphide levels simultaneously
  • 32. GINGIVAL TEMPERATURE  Increased blood flow and a very high metabolic rate  Kung et al Sensitive diagnostic devices for measuring early inflammatory changes in the gingival tissues  PerioTemp probe (Abiodent)= sensitivity of 0.1o C  2 light indicating diodes:  Red-emitting diode higher temp  Green-emitting diode lower temp
  • 33. Diseased sites Posterior teeth Mandibular sites  Temp increases with probing depth = Unknown  Haffajee et. al., 1992  sites with higher temperature have greater than twice the risk of future attachment loss  Pathogens  Increased temperature Unclear
  • 34. TOOTH MOBILITY  Periotest Probe is a hand-held probe,  Mobility is recorded in Periotest units (PTU) from 0 to 50.  The instrument (BioResearch, Milwaukee, Wisconsin, USA) taps each tooth with an impeller 16 times and measures the time taken for the tooth to return to its original position.
  • 36.  Destruction of alveolar bone  Cannot accurately reflect bone morphology= buccally/ lingually  Interproximal bone levels  Root length, root proximity, presence of periapical lesions, estimates of remaining alveolar bone.  More than 30% of bone mass lost  Conventional radiographs are very specific but lack sensitivity
  • 37.  Commonly used  Bitewing  Periapical  Panoramic  Variations in projection geometry  Variations in contrast & density caused by differences in film processing, voltage, & exposure time &  Masking of osseous changes by other anatomic structures (2D mapping of 3D structures)
  • 38. ADVANCES IN RADIOGRAPHIC ASSESSMENT  Digital radiography  Digital subtraction radiography  Computer-assisted densitometric image analysis system (CADIA)  Tuned aperture computed tomography (TACT)  Computed tomography (CT)  Cone-beam computed tomography (CBCT)  Local computed tomography (LCT)  Magnetic resonance imaging (MRI)  Nuclear medicine bone scans  Optical coherence tomography (OCT)  Ultrasound imaging
  • 39. DIGITAL RADIOGRAPHY  Advantages:  The elimination of chemical processing.  Shorter exposure-to-display time.  1/3rd to 1/2rd of dose reduction  Computerized images which can be stored  Selected region in the image can be enhanced for a specific diagnostic task.  The software offers a variety of measurement tools
  • 40.  Two digital radiography systems rely on the sensor –  Direct method  solid-state detectors which are based either on charge-coupled device technology (CCD) or on complementary metal oxide semiconductor technology (CMOS)  key features is the immediate availability of the image  Disadv: limited x-ray sensitive surface of the sensor thicker, rigid & cable attachment besides sterility issue.
  • 41.  Indirect methods: (Digora System)  uses a phosphor luminescence plate, which is a flexible film-like radiation energy sensor placed intraorally and exposed to conventional X-ray tubes.  Adv: plate size and flexibility plates are then erased and can be reused.  Disadv: increased time and effort for scanning
  • 43. DIGITAL SUBTRACTION RADIOGRAPHY  First demonstrated by Zeidses Des Plantes,1935  Principle: current image is superimposed on the previous. Only the areas of change appear  positive difference  brighter  negative difference  darker  Baseline project geometry and image density must be reproduced
  • 44.  A high degree of correlation between changes in alveolar bone determined by SR & CAL changes in periodontal patients after therapy  Increased detectability of small osseous lesions.  Disadv: identical projection alignment during sequential radiograph  Diagnostic subtraction radiography (DSR) positioning device + specialized software
  • 45. COMPUTER-ASSISTED DENSITOMETRIC IMAGE ANALYSIS SYSTEM  Video camera measures the light transmitted through a radiograph and the signals from the camera are converted into gray-scale images.  higher sensitivity and a high degree of reproducibility and accuracy.
  • 46. TUNED APERTURE COMPUTED TOMOGRAPHY (TACT)  To assess tissues in three dimensions  Based on the principle of tomosynthesis:  By shifting and combining a set of basis projections, arbitrary slices through the object can be brought into focus  Improves detection of defects around implants  Tyndall et al., 2002  TACT is superior to conventional radiography in detecting pericrestal bone gain
  • 47. COMPUTED TOMOGRAPHY (CT)  In 1972, Godfrey Hounsfield  The X-ray source travels helically around the patient many times, emitting a narrow fan beam until the region of interest is covered.  The beam exiting the patient is captured in a digital sensor  Axial, coronal or sagittal planes  This is referred to as multiplanar reformatted imaging
  • 48.  Indication for evaluating prospective implant sites for the amount & character of remaining alveolar bone.  Fuhrmann et. al., 1995  CT assessment of alveolar bone height and intrabony pocket is reasonably accurate  Dentascan:
  • 49. CONE-BEAM COMPUTED TOMOGRAPHY (CBCT)  reduced dose of radiation
  • 50.  Drawbacks:  increased effect of scatter radiation on image quality. Scatter radiation reduces contrast and limits the imaging of soft tissues.  CBCT is mainly indicated for imaging hard tissues.
  • 51. LOCAL COMPUTED TOMOGRAPHY (LCT)  A form of CBCT  Uses a small field high resolution detector to generate a limited high resolution 3D volume  advantages of reduced patient dose and low cost  Limited commercial availability
  • 52. MAGNETIC RESONANCE IMAGING (MRI)  Non-ionizing radiation from the radiofrequency (RF) band  Soft tissues have a high water content, MRI provides excellent soft tissue contrast resolution
  • 53.  Adv:  It offers the best resolution of tissues of low inherent contrast.  No ionizing radiation is involved  Since the region of the body imaged is controlled electronically, direct multiplanar imaging is possible without reorienting the patient.
  • 54.  Disadv:  expensive,  requires considerable scan time for high resolution images  may be claustrophobic for the patient  the potential of causing movement of ferromagnetic metals in the vicinity of the imaging magnet  Metals used in dentistry for restorations or orthodontics will not move but may distort the image in their vicinity
  • 55. NUCLEAR MEDICINE BONE SCANS  Radiolabeled pharmaceuticals that are specifically intended to image particular organs or detect specific disease processes.  assessing physiologic change in the absence of anatomic change.  technetium-labeled diphosphonate called 99m-Tc-methylene diphosphonate
  • 56.  To perform a bone scan,  the radiopharmaceutical is injected intravenously.  Following a period to allow for bony uptake of the agent, uptake is either imaged using a gamma camera or measured using specially designed detectors for intraoral use.  Areas of active bone loss appear as hot spots in the image
  • 57.  Used :  determine whether a patient has active sites of bone loss and could benefit from an experimental treatment,  to determine whether a patient who is to undergo a bone marrow transplant has sites of active periodontal disease or occult disease that need immediate attention.
  • 58. OPTICAL COHERENCE TOMOGRAPHY (OCT)  Biologic imaging system in 1991 by Huang et al  high-resolution cross-sectional images of biologic structures by scanning a lightly focused light beam across the tissue  It uses broadband low-coherent Near-Infrared (NIR) light sources  Dental OCT images clearly depict anatomical structures that are important in the diagnostic evaluation of both hard and soft oral tissue
  • 59.  Periodontal tissue contour, sulcular depth and connective tissue attachment  Active periodontal disease before significant alveolar bone loss occurs.  3D imaging of periodontal soft tissues and bone
  • 60. ULTRASOUND IMAGING  Ultrasonics is a branch of acoustics concerned with sound vibrations in frequency ranges above audible level.  Ultrasound imaging, or ultrasound scanning or sonography, is a method of obtaining images from inside the human body through the use of high frequency sound waves.  Non-invasive periodontal assessment tool  1 to 20 megahertz  Spranger (1971) who tried to determine the height of the alveolar crest
  • 61.  Adv:  ultrasound imaging can visualize periodontal and oral tissues in vivo or ex vivo without the need for complicated processing, fixing or staining.  It is fast, easy and a reproducible technique.  non-invasive nature of the imaging  the avoidance of ionising radiation,
  • 63.  Diagnostic microbiology- involves the study of specimens taken from patients suspected of having infection  More than 300 species isolated from different individuals  40 species from a single site
  • 64. Microbiological tests are useful.. 1) To identify putative pathogens and supporting the diagnosis of various forms of periodontal disease 2) To serve as indicators of disease initiation and progression and healing 3) To determine which periodontal sites are at higher risk for active destruction
  • 65. 4) To monitor periodontal therapy 5) To aid in treatment planning of patients with aggressive or non responding periodontitis by helping the doctor in selection of adjunctive antimicrobial therapy
  • 66. ADVANCES IN MICROBIOLOGIC ANALYSIS  Bacterial culturing  Direct Microscopy-dark-field or phase-contrast microscopy  Immunodiagnostic methods  Enzymatic methods  Diagnostic analysis based on Molecular Biology techniques
  • 67. ADVANCES IN CHARACTERIZING THE HOST RESPONSE  Diagnostic tests have been developed that add measures of the inflammatory process to conventional clinical measures.  Information on the destructive process  Current activity of the disease  Rate of disease progression  Patterns of destruction  Extent & severity of future breakdown  Response to therapy
  • 68.  Assessment of the host response refers to the study of mediators, by immunologic or biochemical methods, that are recognized as part of the individual’s response to the periodontal infection  Inflammatory mediators & products  Host-Derived Enzymes  Tissue Breakdown products
  • 69. NEW INNOVATIONS  Proteome analysis  Genetic analysis
  • 70.  Proteome analysis:  Salivary proteome:  using both two-dimensional gel electrophoresis ⁄ mass spectrometry and ‘shotgun’ proteomics approaches  Hu et al. (2005) identified 309 distinct proteins in human whole saliva  NIDCR support salivary proteome projects, 1,166 salivary proteins  3 key features of pathogenic processes in periodontal disease - inflammation, collagen degradation and bone turnover.
  • 71.  GCF Proteomes:  The composition of GCF greatly varies between health and periodontal disease.  Bostanci et al. (2010) performed analysis of the from healthy and periodontally diseased sites  154 proteins of human, bacterial and viral origin were identified in the 40 GCF samples obtained from the 10 subjects  The proportion of bacterial, viral and yeast protein was increased in disease compared to health
  • 72.  Genetic analysis:  The etiology of periodontal disease is multifactorial and thus influenced by genetics (i.e. the host) and the environment  The periodontitis susceptibility trait test (Interleukin Genetics, Waltham, Massachusetts) is the only genetic susceptibility test for severe periodontitis that is commercially available.  This system works by detection of two types of IL-1 genetic alleles, IL1A +4845 and IL1B +3954
  • 73. CONCLUSION  After all these years of intensive research, we still lack a proven diagnostic test that has demonstrated high predictive value for disease progression, has an impact on disease incidence & prevalence, & is simple, safe & cost-effective….  Future application of advanced diagnostic techniques will be of value in documenting disease activity & treatment options.
  • 74. REFERENCES  Newman MG, Takei HH, Klokkevold PR, Carranza FA. 10th edition. Carranza’s Clinical Periodontology. Saunders Company 2006. 579-601.  Ramachandra SS, Mehta DS, Sandesh N, Baliga V, Amarnath J. Periodontal Probing Systems: A Review of Available Equipment. Dentistry India 2009; 3(3): 2-10.  Jeffcoat MK, Wang IC, Reddy MS. Radiographic diagnosis in periodontics. Periodontol 2000 1995; 7: 54-68.
  • 75.  Bostanci N, Heywood W, Mills K, Parkar M, Nibali L, Donos N. Application of label-free absolute quantitative proteomics in human gingival crevicular fluid by LC/MS E (gingival exudatome). J Proteome Res 2010; 9(5): 2191-2199.

Editor's Notes

  1. ) determine is involved to guide selection of the most effective therapy.
  2. which incorporates the advantages of
  3. Inflamed tissues are usually warmer than core body temperature, because of
  4. There is an important dose reduction obtained with this technique (1/3rd to 1/2rd of dose reduction compared with conventional radiographs).1 Enables the use of computerized images which can be stored, manipulated and corrected for under- and over-exposures and hence diagnostic information can be enhanced.1 Either the subjective quality of the image as a whole can be restored or a selected region in the image can be enhanced for a specific diagnostic task.64 The software offers a variety of measurement tools, most of which are digital versions of existing analog tools.64 Integration with existing electronic office and patient-management systems.64
  5. Grondahl et al.  Subtraction radiograph was accurate at lesion depths of 0.49mm. Lesion has to be three times larger to be detected by conventional technique
  6. are the major etiologic factors of chronic and aggressive periodontitis