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
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
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.
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:
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
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
) determine is involved to guide selection of the most effective therapy.
which incorporates the advantages of
Inflamed tissues are usually warmer than core body temperature, because of
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
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
are the major etiologic factors of chronic and aggressive periodontitis