Physical Evaluation and Treatment Planning in Dental Practice: Chapter 10 - Periodontal and Peri-Implant Examination
A thorough periodontal and peri-implant examination is the foundation upon which all diagnosis and treatment planning rests.
Dr. Theo Katsaros
Periodontist
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Background & context
A thorough periodontal and peri-implant examination is the foundation upon which all diagnosis and treatment planning rests. Without a systematic, structured approach to examining the periodontium and peri-implant tissues, disease can go undetected, under-staged, or misclassified leading to inadequate treatment, missed referral opportunities, and avoidable disease progression.
This chapter summary, originally published in Physical Evaluation and Treatment Planning in Dental Practice and written by Dr. Theo Katsaros and Dr Guy Huynh-Ba, provides a comprehensive framework for periodontal and peri-implant diagnosis, from the basic classification of disease states through to treatment planning principles and the specific considerations that apply to implant patients.
The diagnostic framework presented reflects the 2017 World Workshop classification system, which introduced important refinements — most notably the elimination of the chronic/aggressive periodontitis distinction and the introduction of Stage and Grade as the primary axes for characterizing disease severity and progression rate.
Periodontal disease classification
Periodontal status is organized into three primary categories, each with distinct clinical definitions and diagnostic criteria.
Healthy Periodontium | Gingivitis | Periodontitis |
|---|---|---|
No plaque-induced periodontal disease PD 1–3 mm · BOP at fewer than 10% of sites · No redness or swelling · Can be intact or reduced periodontium | Inflammation without attachment loss BOP >10% · Redness and swelling present · No true periodontal pocket · Localized (<30% teeth) or generalized (≥30% teeth) | Inflammation with attachment and bone loss Apical migration of junctional epithelium · True periodontal pocket present · Classified by Stage (I–IV) and Grade (A–C) |
Diagnosing periodontitis: criteria & classification
The diagnosis of periodontitis requires one of the following to be present, with attachment loss attributed solely to periodontitis and other causes excluded:
Clinical attachment loss at the interproximal surfaces of two or more non-adjacent teeth; or buccal/lingual attachment loss with probing depths of 4 mm or more at two or more teeth.
Once diagnosed, periodontitis is classified by extent (localized: ≤30% of teeth; generalized: >30% of teeth; or molar-incisor pattern), and then assigned a Stage and a Grade.
Staging: severity and management complexity
Stage | CAL | Radiographic bone loss | Tooth loss | Complexity |
|---|---|---|---|---|
I | 1–2 mm | Coronal third | None | PD ≤4 mm, mostly horizontal bone loss |
II | 3–4 mm | Coronal third | None | PD ≤5 mm, mostly horizontal bone loss |
III | ≥5 mm | Middle or apical third | ≤4 teeth | PD ≥6 mm, vertical bone loss ≥3 mm, Class II/III furcation |
IV | ≥5 mm | Middle or apical third | ≥5 teeth | Complex rehabilitation required; masticatory dysfunction, bite collapse, pathologic migration |
An important distinction
A patient's Stage does not typically change over time — it reflects the cumulative damage already done. Grade, however, can change as systemic modifiers evolve. For example, a patient with poorly controlled diabetes (Grade C) who achieves HbA1c control may shift to Grade B. This makes Grade a dynamic, clinically actionable variable.
Grading: rate of progression and systemic impact
Grade | Progression rate | Evidence of progression | Risk modifiers |
|---|---|---|---|
A — Slow | No bone loss over 5 years | % bone loss/age <0.25; heavy biofilm with low destruction | Non-smoker; non-diabetic |
B — Moderate | <2 mm bone loss over 5 years | % bone loss/age 0.25–1.0; destruction commensurate with biofilm | <10 cigarettes/day; HbA1c <7% |
C — Rapid | ≥2 mm bone loss over 5 years | % bone loss/age >1.0; destruction inconsistent with biofilm; early onset patterns | ≥10 cigarettes/day; HbA1c ≥7% |
Acute conditions & combined lesions
Necrotizing periodontal diseases
Necrotizing gingivitis (NG), necrotizing periodontitis (NP), and necrotizing stomatitis (NS) are acute inflammatory conditions characterized by ulcerated, necrotic papillae covered by a grey-yellow pseudomembrane, severe pain, and fetor ex ore. NG and NP are most common in healthy individuals aged 20–30 experiencing stress or malnutrition — including students during exam periods and military personnel. NP and NS in more severe form are strongly associated with immunocompromised patients, including those who are HIV positive. Risk factors include poor oral hygiene, smoking, stress, malnutrition, and impaired immune function.
Periodontal abscess
A periodontal abscess is an acute bacterial infection typically associated with a pre-existing deep periodontal pocket, presenting with localized swelling, pain, purulent exudate, tooth mobility, and percussion sensitivity. It most commonly develops when pocket margins reattach over calculus, trapping bacteria in the apical pocket — often following incomplete non-surgical debridement. Differential diagnosis from an abscess of endodontic origin is essential: periodontal abscesses are associated with a positive vitality test, localized angular bone defects, and a history of periodontal disease, while endodontic abscesses feature negative vitality, periapical radiolucency, and diffuse pain.
Combined endodontic–periodontal lesions
Combined lesions arise when periodontal and endodontic disease processes converge. Three pathways exist: a primary endodontic lesion extending to the periodontium; a primary periodontal lesion progressing to involve the pulp retrograde; or two distinct lesions uniting. Diagnosis is complicated by shared clinical and radiographic features. The 2017 classification organizes these lesions by the presence or absence of root damage (fractures, perforations, resorption) and, within each category, by the number and distribution of deep pockets. Treatment must address both components — endodontic therapy followed by appropriate periodontal management — with prognosis dependent on the nature of the periodontal defect.
Periodontal treatment planning: the six-phase model
Phase 1 | Systemic phase — ensure the patient can safely undergo periodontal therapy; liaise with physicians where systemic conditions (e.g. diabetes, bleeding disorders) require optimization before treatment begins. |
Phase 2 | Cause-related therapy (non-surgical) — patient education and oral hygiene instruction, followed by full-mouth debridement to remove calculus and overhanging restorations. The goal is reduction of pathogenic microflora. |
Phase 3 | Reevaluation after cause-related therapy — comprehensive reassessment to determine whether further intervention is needed. Stage I and II periodontitis may resolve and transition directly to maintenance. Stage III and IV cases typically require surgical intervention. |
Phase 4 | Surgical phase — indicated when unresolved pockets, attachment loss, or bone defects persist after cause-related therapy. May include resective surgery, regenerative procedures, or both. Patient cooperation and plaque control must be adequate before surgery proceeds. |
Phase 5 | Reevaluation after surgical phase — documents disease resolution and establishes the baseline for maintenance. If cooperation remains inadequate, surgery is contraindicated and disease resolution is unlikely. |
Phase 6 | Maintenance phase — ongoing recall every 3, 4, or 6 months. Reinforces oral hygiene, monitors PDs and BOP, instruments deepened sites as needed, and prevents disease recurrence. Maintenance begins immediately after cause-related therapy — not after surgery. |
Peri-implant examination & diagnosis
The peri-implant examination mirrors the periodontal examination in structure but requires important modifications. Probing is performed with reduced force (approximately 0.15 N), using a plastic probe where possible for better adaptation to abutment contours. Healthy peri-implant probing depths are slightly deeper than periodontal health norms — up to 5 mm — due to anatomical differences in the peri-implant seal.
A critical distinction from natural teeth: any implant mobility, regardless of the amount of bone loss present, indicates implant failure and warrants removal. Following placement, up to 2 mm of crestal bone remodeling in the first year is considered within normal limits.
Diagnosis | Clinical inflammation | BOP / suppuration | Increased PD | Bone loss |
|---|---|---|---|---|
Peri-implant health | Absent | Absent | Absent | Absent |
Peri-implant mucositis | Present | Present | May be present | Absent |
Peri-implantitis (with prior exam) | Present | Present | Present | Present (>2 mm) |
Peri-implantitis (no prior exam) | Present | Present | PD ≥6 mm | ≥3 mm from implant platform |
The importance of referrals |
|---|
Most patients presenting in general practice will have gingivitis or Stage I–II periodontitis, which can be appropriately managed in that setting. More severe cases — Stage III, IV, molar-incisor pattern, or complex peri-implant disease — require specialist involvement. The general practitioner's responsibility is to diagnose accurately, recognize their limitations, and refer in a timely manner. Early diagnosis and timely referral are among the most consequential decisions a general practitioner can make for a patient's long-term periodontal prognosis. |
Chapter Reference
Summarized and abstracted from: Katsaros T. Chapter 10: Periodontal and peri-implant examination. In: Physical Evaluation and Treatment Planning in Dental Practice. Wiley-Blackwell; 2021.
