Prof. (Dr.

) Anirban Chatterjee, MDS, PhD,

Fellowship
Prof. (Dr.) Anirban Chatterjee
Head – Department of Periodontics
The Oxford Dental College
MDS (Periodontics)
Ph.D. (Dental Sciences)
Fellowship-ICOI (Implantology)
ROBINHOOD
Advanced Diagnostic
Aids
Contents
 Introduction
 General purposes of diagnostic procedures
 Diagnosis of periodontal diseases
 Conventional periodontal diagnosis- limitations
 Advances in clinical diagnosis
Periodontal probes
Gingival bleeding
Gingival temperature
Tooth mobility
 Other diagnostic techniques
 Radiographic techniques
 Limitations of conventional radiographs
 Advances in radiographic techniques
 Imaging methods in periodontology
Intraoral & extra oral radiography
Digital radiography
Ultrasound imaging
Nuclear bone scanning
Specialised techniques
 Advanced microbiological diagnostic aids
 Problems with microbial diagnosis
 Bacterial culturing
 Direct microscopy
 Immunodiagnostic methods
 Enzymatic methods
 New molecular technologies-DNA probes & PCR
 Advances in genetic assessment
 Advances in characterising the host response
 Saliva & GCF as a source of biomarkers
 Various potential markers of host response
- Inflammatory mediators and products
- Host-derived enzymes
- Tissue-breakdown products
 Conclusion
 Bibliography
Introduction
 Diagnosis of a disease is mainly based on the etiology,
pathogenesis and the clinical symptoms associated with the
specific condition (as in case of mono infecitous conditions
like tuberculosis) but it is not so with the periodontal diseases
because of the multifactorial etiology and polymicrobial
nature of periodontal infections.

 with the continued research in the field of periodontal

microbiology and immunology the concept of disease
etiology and pathogenesis is changing continuosly. (from
clinical charecterstics paradigm to host response paradigm)

 As we know that the correct diagnosis of the disease forms

the strong foundation for accurate treatment and
favorable patient outcome it is our duty to consider and
choose a proper diagnostic aid that are useful for
particular patient.
DIAGNOSIS DEFINITION-
Dr.(Prof) ANIRBAN CHATTERJEE MDS,,Ph.D

 The identification of the nature of an

illness or other problem by examination of
the symptom with the assistance of
laboratory investigations.
General Purposes Of Periodontal
Diagnostic Procedures
Screening.

Diagnosis of
specific
Monitoring
periodontal
diseases

Identification of
Treatment planning. sites or subjects
at an increased
risk.
At present we are handicapped in making precise
diagnosis & prognosis by 2 important limitations:

• No reliable marker for disease

activity

• No reliable criteria for

identifying the at risk
individuals
 Diagnosis Of Periodontal Diseases
Diagnosing periodontal diseases involves several decision nodes or
levels:- ( page1992)

2nd level: Able to

1st
level: Able to differentiate
diagnose between
health versus gingivits,periodontiti
disease s

3rd level Able to

classify
different types

Lastly,the decision as to
determine whether the disease is
active or arrested or in remission
 Traditional Diagnostic Procedures
 suffer from a number of drawbacks such as:

• Not precisely accurate

• Provide only retrospective information
• Not reproducible
• Cannot reliably identify sites with ongoing destruction.

Therefore not entirely suitable for monitoring the progression

of periodontal disease.
Advances In Clinical Diagnosis
Advances in mouth mirror
Illuminating mouth mirror
PROBING THE PROBES
 Periodontal Probing

 G.VBlack- First to describe use of the periodontal

probe to explore periodontal pockets.
Generations Of Probes
Philstrom [1992]
 Gen I: Conventional probes.
 Gen II: Pressure sensitive.
 Gen III: Computerized.

Watts [2000]

 Gen IV: Aim at recording sequential probing

positions along the gingival sulcus.

 Gen V: Ultrasonic device attached to the

4thgeneration probe.
Gen I:Manual Probes

Diadvantages:

Errorsin manual recording

Pain provoked by probing
Variability in probing force, diameter
Lack of stable reference point
Criteria For Automated Probes

Precision = 0. 1 millimeter
Range = 10 millimeter
Probing force = Constant & standardized
Applicability = Non Invasive, but easy to use
Reach = Easy to access any location
Angulations' = Guidance system for proper
angulations
Security = Complete sterilization of all portions
entering
the mouth
Read out = Digital
Recorded = Digital
Gen II: Pressure Sensitive Probes
 Theseare introduced by Gabathuler & Hassel in
1971.-probe with piezoelectric pressure sensor

 Armitage in 1977, designed

a pressure sensitive probe
holder to standardize the
insertion forces.
 At force of 25ponds different
levels probe penetration
varing with the tissue consistancy
 In1978, Van der velden & De vries: Developed
pressure sensitive probes.

Vitek et al 1979 designed a leaf spring force controlled

probe.
 The instrument delivers a force within 0.5gms to a
Michigan ‘O’ probe with a tip diameter of 0.35+/-
0.05mm.
Tromp et al 1979: Introduced new periodontal
probes to increase the reproducibility of
pocket depth measurement.
 Modified in such way that the force exerted
by the probe was independent of the force
applied by the operator.
 Comparison between this probe and Williams
probe:
Average variance of 0.31mm for new probe
and 0.60mm for williams probe.
 In 1980 Van der Velden & De Vries : Modified
Pressure sensitive probes to eliminate the incorrect
reading & used a displacement transducer & a
electronic pocket depth read out.
 Probing force was produced with a coiled spring(air
pressure)
Vine valley Probe
 Introduced by Polson et al 1980
 It is an electronic pressure sensitive probe that is
not sensitive to lateral forces and not subjected
to error due to gravity.

 Itallows control of insertion pressure & permits the

use of different types of probe tips.

 The pressure force varies with a range of

sensitivity of 5-100gms
Parts:
 Handpiece –allows the insertion of probe
 control box-allows the examiner to set the
probing force.
 When desired preset force is attained a
beep is heard.
Viva Care TPS [Vivadent]
 This true pressure sensitive plastic probe was described by
Hunter in 1994.
 Has a disposable probing head

Advantages:
- Standardization of probing tip [1mm]
-Addition of registration stents to maintain reproducible
probing angulations
-Additional rim surrounding the side of the ball helps in detecting
the CEJ, overhangs etc.
Disadvantages:
- Techniques for data readout & storage are inaccurate and
again is time consuming.
COMPARATIVE STUDIES
 Van der Valden & De Varies reported-
 Neither intra or inter examiner variability
improved with a controlled force of 0.75N.
 No difference in reproducibility between
a controlled force probe & a manual
probe in shallow or deep pockets.
Thus,
“The failure of constant force probes to
dramatically improve exact
reproducibility is a clear indication that
sources of error other than probing force
variation are involved."
Van Der Velden & De Vries [1980]:
In a Comparative study of manual & pressure sensitive
probes, stated that a standardized probing force
does not lead to a more reproducible pocket depth
measurements.

Hunter ,Martin [1991]:

Comparative study of manual &
probes, observed that a pressure
uniform dimension provides more
& consistent data for the
periodontal status.
pressure sensitive
sensitive probe of
accurate, reliable
measurement of
Rams & Slots in 1993-
 Compared 2 pressure sensitive probes & a manual
probe in shallow & deep pockets.
 All the 3 probes - higher standard deviations with
increasing depth,
Results-The pressure sensitive probe yield more
reproducible probing depth measurements than a
manual probe.
Gen III: Automated & Computerized
Periodontal Probes
Third generation probes combine –
 Controlled force,
 Automated and computerized data recording.

Advantage:
 Automated data capture,
 Thus facilitates data entry into patient records &
eliminates error in data.
 Florida Probe

 Introduced by Gibbs et al in 1989.

 Combined advantage of constant probing force
 with precise electronic measurement
 computer storage of data
 and also has a guidance system that ensures
reproducible pathway.
Probe tip similar to common Michigan ‘o’ probe with
williams markings.

 Two models: The stent & disk models

Stent Model
Disk Model
 Florida Probe with a
Titanium tip for the implant.

Reproducibility is superior to manual probes with SD of

0.21-0.28mm
 Advantages Limitations

 Lightweight  Lacks tactile sensitivity

autoclavable
handpiece.
 Uses a fixed force setting
 New titanium tips for
implants
 Underestimation of PD and
CAL. [Greenstein 1997]
 Standardizedprobing
force-0.2mm resolution

 Overridebutton on hand
piece to walk the sulcus
 Inter Probe
Goodson & Kondron et al in 1988 – fiber optic
technology.
It includes
 a control unit,
 2 memory cards
 hand piece,
 dot matrix printer,
 foot switch,
 chart forms &
 disposable probe tips.
The filament tip moves to the base of the pocket
while the rest of the filament translates into the
sheath.

 Florida probe & the Florida disk probe have

The
a resolution of 0.1 mm,

while the Interprobe has resolution of 0.5mm.

Foster Miller Probe

 Jeff coat introduced this probe in 1986

 Asit moves along the root surface, the tip

experiences a sudden change in
acceleration when the CEJ is crossed.

 Similar
change in acceleration is recorded
when the probe tip reaches the depth of
the pocket.
 Toronto Automated Probe
• Introduced by karim M etal (1990).
• To improve the consistency of probing angulations.

• The probe consists of a digital length gauge

• which is connected to a nickel titanium wire 0.5mm
in diameter enclosed in a polyethylene sheath.

• The probe is propelled by air pressure into the gingival

sulcus with a regulated force.

• Mercury tilt sensor limits angulations with in 30•

 Birek Probe

 Introduced by Birek in 1987- for gingival attachment levels

 Works by constant air pressure & uses the occlusal /incisal

surfaces as the reference point

 Probe angulation maintained by mercury level switch at

the probe handle.

 It has a SD of 0.46mm & subject threshold as 1.38mm

 Periprobe Comp
 It is a computerized electronic probe

 Consists of a hand piece & a disposable probe

sleeve unit with a ball shaped end point of 0.5mm
in diameter.

 It contains a closed in spring which controls the

probing pressure.
 Generation V: Ultrasonic Probes
A non invasive ultrasound technique to detect, image
& map the pdl
 One of the key technical obstacles- Designing an
ultrasonic probe that would be small enough to be
useful, but yet transmit & receive sufficient signal
strength.
 Advantages
 Ultrasoundgives more information- as secondary
echoes are recorded from tissues at various depths.

 Thismay provide valuable data to aid the clinician in

the diagnosis & treatment charting of the disease.
 Gingival Bleeding

 Gingival bleeding is a sensitive clinical

indicator of early gingival inflammation

 Clinical advantage of being more

objective.

 Good indicator of the presence of an

inflammatory lesion in the connective
tissue
Lang et al in 1991[Retrospective study]-
Sites that bled on Probing at several visits had a
higher probability of losing attachment than
those that bled at one visit or did not bleed.
- Limited predictive value for disease progression
- Absence indicates periodontal stability with high
probability

Limitation: Healthy sites may bleed on probing if

force is greater than 0.25 N
 Gingival Temperature

Extensive study to assess subgingival temp is done by:

Kung et.al 1990 and Haffajee et. al 1992

PERIO TEMP probe

[Abiodent]
Subgingival temperature- Has good specificity
but poor Sensitivity when considered alone as a
marker for progressive periodontitis.
 Rationale for  in temp with  in pocket depth:
 Endotoxins of infecting bacteria, especially
lipopolysaccrides from Gram –ve organisms,
exogenous pyrogens, that stimulate macrophages
to release endogenous pyrogens, producing fever
[Bencsics et al 1995]

 Alteration in the cellular and molecular activity of

bacteria [Maurelli et al 1989]
 Tooth Mobility

 Tooth mobility is a clinical expression of

periodontitis.

Perio test

 Itutilizes dynamic forces of short duration

of low millisecond range.

 Evaluates the damping characteristics of

the tooth.
Perio Test

Ranges:
-8 to +9 : Clinically firm tooth

10-19 : Palpable mobility

20-29: Visible mobility

30-50 : Mobility in response
to lip & tongue movements
Periotest values for implants
- 08 to -01: Implant is well osseointegrated
00 to +09: Clinical examination is necessary
+10 & higher: Suspicious alarming. Implant is not
sufficiently osseointegrated.
Errors- Due to variation in duration, point & mode of
application, manner, & time of force applied.
 DetectarTM
The DetectarTM system [Ultradent, Salt Lake City]
subgingival calculus diagnosis by evaluating the
root surfaces
 Light is emitted onto the root surface through a
flexible fiber.
 Reflections of the this light are also sensed by the
optical fiber & converted into an electrical signal
for analysis.

A computer processing algorithm determines

whether the Detectar probe has detected calculus,
and activates an auditory & light signal thus
notifying the clinician of the presence of calculus
[Felix Krausse Nad Andreus Braun 2004]
 Home Screening Tests [HST]

 Introduced by Kopezyk et al in 1995.

 Occult blood in saliva is correlated to gingival

inflammation.

 This method demonstrates sensitivity of 75.9% &

Specificity of 90.5% for the detection of gingival
inflammation
ADVANCES IN ASSESSMENT OF HALITOSIS
 Halimeter
 Introduced by Rosenberg et al in 1991.
 Itsperformance lacks specificity in the analysis of
the different components of mouth air in
comparison to the gold standard gas
chromatography.
[Tonzetich et al 1995]
BANA TEST
 Diamond Probe/ Perio 2000 system

It has been designed so that it combines the features

of a periodontal probe with the detection of volatile
sulphur compounds in the periodontal pocket.
Dental Endoscope
 It is introduced for use, subgingivally in the diagnosis
& treatment of periodontal disease.

 Produced by Dental View, Inc.- called as Perioscopy

system.

 It consists of 0.99mm diameter reusable fibroptic

endoscope over which is fitted a disposable, sterile
sheath.

 The fibroptic endoscope fits on to the periodontal

Probes and ultrasonic instruments that have been
designed to accept it.
Dental endoscope viewing furcation
An endoscopic view of
residual burnished Viewing subgingival calculus
calculus. in a severely inflamed
pocket.
Uses:

1. Allows clear visualization of deep subgingival

pockets & furcations.

2.Enables operator to detect the presence &

location of subgingival deposits and guides the
operator in their removal.

3. Possible to achieve levels of root debridement &

cleanliness that are much more difficult to
produce without it.
Advances In Radiographic Techniques
 Conventional Radiographs

Traditional methods for assessing the destruction of

alveolar bone associated with periodontal disease

 Information about the past disease activity

 They are specific but not sensitive

2 types of views in conventional radiographs:

- Intra Oral periapical radiographs
- Ortho pantamographs
Intra Oral Periapical
Radiographs Extra Oral Radiographs
Limitations Of Conventional Radiographs
1. It is a 2 dimensional representation of a 3
dimensional structure.

2. Only interproximal alveolar bone levels can be

assessed with some level of certainty.

3. They do not reflect the current disease activity.

4. Sufficient bone should be destroyed to be

detected.
5. Radiographs are specific but not sensitive.

6. Misdirection of the central ray of the X-ray beam+

exposure and processing errors further limit
accuracy.

7. Most importantly morphologic or pathologic

aspects of the alveolar bone may go undetected
as a result of superimposition of teeth and other
anatomic structures.
Digital Radiography
 Digital radiography utilizes digital detectors
and they serve as a viable alternative to film-
based imaging.

 Offers a number of advantages

 Currently there are 2 technologies

 1. Solid state detectors-- CCD,
CMOS(complimenatry metal oxide
semiconductors)
2. Photo stimulated phosphor system
 Image processing can be used to enhance the
Perceived quality, either to restore the subjective
quality of the image as a whole or to enhance a
selected region in the image for specific diagnostic
task.
 Active image area are currently very similar to the
IOPA but the sensors are considerably thicker than
film which together with their rigidity & cable
attachment, can make sensor placement more
challenging & patient discomfort more likely.
 Direct Digital Radiography

 Thisuses solid state detectors, which are based

either On CCD technology or on CMOS
technology.
Indirect Digital Radiography
 Based on the Photo stimulated Phosphor system
also called as storage Phosphor.

 The PSP plates are dimensionally comparable to

films & are handled similarly.

 Exposed plates are scanned in an external laser

scanner, which generates the digital image for
storage and display on the computer.
Advantages

 High speed
 Low exposure
 Ability to manipulate the image & increase
diagnostic efficacy
 Improved patient education
 Ease of storage, transfer & copying
 Disadvantages

 Requires familiarity & understanding

 Cannot correct a grossly overexposed or under

exposed projection

 Image enhancement should be used with

caution & should be task oriented.
Specialized Radiographic
Techniques
 Digital Subtraction Radiography

 1stintroduced to medical literature by Zeidses Des

Plantes in 1935.
 Later Grondhal & Grondhal [1983] introduced this
technique in Periodontal diagnosis.

 Jeffcoat et al [1992] used to determine periodontal

disease
 This
technique is very sensitive and it can detect
0.12mm change [Rudolph 1987]

 The image i.e. obtained is an isolated structure that

have undergone the change.
 Once the subtracted image is formed, it is
electronically contrast enhanced to display the
final image.
 Colorcoding of images:
Bone gain: Shades of green
Bone loss: shades of red
 DSR In Periodontology
 High degree of correlation b/n changes in alveolar
bone & CAL changes in patients after therapy.
[Hausmann et.al, 1985]

 Increased detection of small osseous lesions

compared with conventional radiographs from
which the subtraction images are produced.

 Main disadvantage- Need to be almost at identical

projection alignment during the exposure of
sequential radiographs which makes this method
impractical in clinical setting.
Tuned Aperture Computed Tomography
[TACT]
 TACT was developed for the 3-Dimensional
assessment of the dento alveolar tissues, without the
high cost & dose, associated with CT.

 TACT is built on the basic principle of tomo-synthesis &

by shifting & combining a set of basic projections,
arbitrary slices through the object can be brought
into focus [Ruttiman et al 1989]
 Thediagnostic efficacy of TACT for imaging the
alveolar bone has been tested & has shown to
improve the ability of observers to detect osseous
defects around implants. [Lang et al 1999]

 Nair et al 2001- Reported that TACT & TACT

subtraction for the detection & localization of
osseous changes in crestal bone are encouraging.
 The basic projections are conventional
transmission radiographs. Each radiograph is
taken from a different angle relative to the
object and the receptor.

 Eachslice is a two dimensional representation of

the object at a different location in a third
dimension. [Webber et al 1997].
Tuned Aperture Computed
Tomography [TACT]
Computer Assisted Densitometric Image
Analysis System [CADIA].
 CADIA - A video based technique introduced to
periodontal diagnosis by Bragger et al 1988.
 Itis possible to manipulate the images.
E.g: To change the contrast.

 Tooth root & alveolar bone height can be

measured to an average of 0.01mm.

 It
is the most sensitive method of visualizing the
alveolar crest-CEJ & measuring the radiographic
bone loss in periodontal surgical site.
[Udyan Gupta 2002]
 Computed Tomography

 In1972 Godfrey Hounsfield invented this

revolutionary imaging technique - Computerized
axial transverse scanning.

 This3-dimensional information helps in assessment of

alveolar bone height.

 Ituses a rotating fan beam to image a thin slice of a

structure at a time, generally in a axial orientation
Modern CT machines use
a continuous table
motion
During image acquisition,
resulting in the spiral or
helical image formation.
 Once the image volume has been generated,
image slices can be reconstructed in various
orientations through a process called multi-planar-
reformatting.

 Although the level of image detail remains

considerably lower than with conventional Intraoral
imaging, these advancements in CT technology
satisfy almost all periodontal imaging needs from
an pure technical and possibly diagnostic
perspective.
[Fuhrmann et al 1991,1995, Pistorious et al 2000]
Advantages of CT
 Eliminates the superimposition of images of structures
outside the area or site of interest.
 Because of the inherent high contrast resolution,
differences between tissues that differ in physical
density by<1% can be distinguished.
 Data formed consisting of either multiple contiguous
or one helical scan. Can be viewed as an image in
the axial, coronal or sagital plane.
 Limitations of CT

 Ekestubble et al1993 & Scaff et al 1997- Reported

that the effective dose of CT for imaging is much
higher than conventional radiography.
 Unfavorable cost-benefit ratio.
 Acquisition of high-resolution CT images remains a
high-dose procedure.
 Another major drawback included the limited
availability of medical CT imaging to dental health
care providers.
 Cone Beam CT

 Cone Beam CT like the conventional units, can also be

used to generate 3-D CT images at a much lower
radiation
dose.
 Thesimplified design of the Cone Beam CT unit also
allows for considerable cost saving as compared to
medical CT units.

 Disadvantages: Is the increased effect of scattered

radiation on the imaging quality.
 The Newtom QR-DVT:9000 is a large CBCT unit, initial
dose estimated for this unit indicate that a full scan
of the
mandible & the maxilla generates an effective dose
approximately 3-6 times that of a single panoramic
radiograph.
 Main application of this unit include-
Implant site evaluation
Orthodontics
Maxillofacial surgery and
TMJ imaging.

 Investigations
regarding the usefulness of
CBCT for periodontal applications are in
progress
 Local CT
 LCTuses a small-field high-resolution detector to
generate a limited high-resolution 3-D volume.

 The field volume size varies, but is generally

comparable to the dimensions of conventional intra
oral radiographs.
 LCT generates image detail in 3-D while retaining
the advantages of reduced patient dose and
reduced cost.

This makes the use of LCT particularly suited for

dental radiography.
 Interactive CT

 This pre operative planning also allows for a determination

of the need for adjunctive grafting procedures.

 By including information about the prosthetic end result

in the CT scan, the final prosthetic position can dictate
the implant placement.

 The utilization of this treatment planning technology

creates excellence in dental implant treatment and offers
simplicity for the practitioner.
 Magnetic Resonance Imaging [MRI]

 MRI uses non ionizing radiation

 It essentially involves the behavior of protons -

positively charged nuclear particles in a magnetic
field.

 MR images are obtained by measuring changes in

low frequency radio signals in the magnetic field.
 The resulting data can be used to create images of
the structures examined or chemical profiles of the
tissues.
 This
technology gives better soft tissue
images than CT and the patient is not
exposed to radiation.

 MR imaging is mainly used in the study of

TMJ and the soft tissue lesion of gingiva
and other oral structures.
 Advantages over conventional:

 Offers the best resolution of tissues of low

inherent contrast.
 No ionizing radiation is involved.
 Because the region of the body imaged in MRI
is controlled electronically, direct multiplanar
imaging is possible without re-orienting the
patient
 Disadvantages

 Long imaging times

 Potential hazard imposed by the presence of
magnetic metals in the vicinity of the imaging
field
 Expensive
 Bone does not give a MR signal, a signal is only
obtained from the bone marrow
 Contraindicated in patients with cardiac pace-
makers
 Applications
• Excellent soft tissue contrast resolution.
• For diagnosing suspected internal derrangements of
the TMJ
• Post surgically evaluating treatment outcomes of
those derangements.
• Identifying and localizing orofacial soft tissue lesions
• For imaging salivary gland parenchyma.

 MR imaging of periodontal tissues before and after

initial therapy might be a useful tool for quantification of
periodontal inflammation.
 Ultrasound Imaging
 Scanners used for sonography generate electrical
impulses that are converted into ultra – high
frequency
sound waves by a transducer
[a device which converts One form of energy into
another]

 The most important component of the transducer is

a thin piezo electric crystal made up of a great
number of dipoles arranged in a geometric pattern.
Most widely used piezo electric material is lead
zirconate titanate (PZT).
 As the ultra sonic beam passes through, or interacts
with, tissues of different acoustic impedance, it is
attenuated by a combination of absorption,
reflection, refraction and diffusion.

 Sonic waves that are reflected back (echoes)

toward the transducer causes a change in the
thickness of the piezoelectric crystals, which in turn
produce an electrical signal that is amplified,
processed and ultimately displayed on a monitor.
 Application in dentistry

 Examination of hard tissues

 Periodontal ligament space
 Determine bone morphology
 Measurement of furcation involvement.
 For evaluation of fibrosis of oral mucosa
 As a method to demonstrate the thickness of the
masticatory mucosa.
Optical Coherence Tomography [OCT]
 OCT generates cross-sectional images of
biological tissues using a near-infrared light
source.

 This light is able to penetrate into the tissue

without harming the cells.

 Differences in the reflection of the light are used

to generate a signal that corresponds to the
morphology and composition of the underlying
tissues.
Radio Visio Graphy [RVG]
 RVG consists of 3 components:
• Radio Component
• Detector / Image receptor
• Graphy component
Advantages:
• Immediate image display
• Ability to manipulate the image
• Patient dose reduction of 60%
Photo Densitometric Analysis Technique
 Itis based on the absorption of a beam of light by
the radiographic film which shows the image of an
aluminum scale

 Italso has the ability to transform density reading

into 1mm of aluminum equivalent.

 Thisis accomplished by a microdenstiometer linked

to a microcomputer.
 This
technique requires a parallelization technique to
obtain accurate super imposable radiographs.

 Advantages:
1. Allows detection & recognition of variations that
cannot be detected by visual inspection,
2. Helps to quantify bone changes & study the
furcation areas [Edwin et al 2000]
Nuclear Medicine [Bone Scanning]
 Nuclear medicine technique represents an effort
to develop ways of detecting active change in
bone metabolism around teeth long before the
loss of bone is perceived on a radiograph.

 Goldhaber and co-workers applied Nuclear

Medicine to study periodontal bone resorption in
the early 1970’s.
 Use radio pharmaceuticals such as technetiun-
99m a short lived element with a 6 hour physical
half life.
 Forbone studies- Technitium-99m is coupled with
tin & Diphosphonate moiety giving the radio
pharmaceutical its bone seeking ability.

 Kaplan et al observed that beagle dogs with

advanced bone loss had 6 times greater
alveolar bone seeking radiopharmaceutical
uptake as compared to beagle dogs with no
bone loss.
 Absorptiometry

 It is a non-radiographic method introduced by

Henrikson et al
 Is the most sensitive technique for analyzing
periodontal bone changes with a high degree of
accuracy and precision.
DENTASCAN

-The CT Dentascan - specially - to obtain true cross-sections of the

mandible and maxilla from the easily obtained CT scans
-Specialized type of computed tomography (CT or “CAT” scan),
which is performed on a conventional CT scanner used to obtain
true cross-sections of the mandible and maxilla.

Applications – in patients with :

oCyst& Tumours
oDistractions
oJaw Growth
oStages Of Tooth Development
oDental Implant
oCases Of Fractures - Mandibular Or Maxillary Arch
-Main use of dentascans today - pre-operative planning and
modeling of endosseous dental implants and subperiosteal
implants.

- Enables the dental surgeon to visualize the bony structures pre-

operatively - does not have to make decisions at the time of
surgery to visualize the bony structures directly.
OSTEOSCAN

- Aka - DXA ( Dual Energy X-Ray Absorptiometry )

-The X-ray beam contains two distinct energy peaks.

-One - absorbed by soft tissues and
-Other – by bone.

-By subtracting one reading from the other a figure is

produced - represents the bone mineral density.
Scoring
T-Score compares your reading with that of healthy bones in
people aged approximately 30 (peak density) .

> -1 : no action is usually taken.

-1 and -2.5 : OSTEOPENIA – (bone density between Normal and

Osteoporosis - May be recommended treatment.)

≥2.5 : OSTEOPOROSIS.

-The Z-Score compares your reading with healthy bones in your age
group.
 CONCLUSION
 For most cases conventional diagnostic methods
are sufficient to design an effective, appropriate
treatment plan.
 Research evidence indicates that our traditional
diagnostic criteria such as gingival edema, redness,
plaque, bleeding and exudate have fair specificity,
but poor sensitivity in diagnosing sites or patients with
“active” disease progression (Haffajee et al 1983).
 It is the minority of clinical cases,where the
experiencd clinician does not see the treatment out
come as expected and thus may require these
advanced diagnostic aids.
 The development of automated periodontal
probing represents refinements of traditional
diagnostic tools for detecting subtle anatomic
changes occurring in periodontal tissues.

 These techniques have immediate application

in today’s cutting edge practice, especially
those servicing high risk, maintenance patients.

 These advancements reiterate the importance

of close patient monitoring and case
documentation.

 The digital era is only in its infancy and there is

already a lot of new imaging technology in the
market.
Advanced Microbiological Diagnostic
Aids
Problems With Microbial Diagnosis
 Polymicrobial nature of periodontal diseases.
 Utility of microbial identification as an aid in
treatment
planning is tested in a limited number of studies,
mostly case reports.
 Furthermore the use of microbial diagnosis resulted
in use of more systemic antibiotics.
 The absence of these pathogens is a better
indicator of
periodontal health than their presence in most of the
sites
 Diagnostic Tests For Microbiological
Analysis
Specific
Non Specific Analysis

Culture & Sensitivity Immunological assay

Microscopy Enzyme based
Assay -Direct & Indirect IFA,
-Flow Cytometry,
-Latex agglutination,
-ELISA
-PCR & DNA probes
 Bacterial Culturing
 Itis considered as a “Reference method /Gold
standard” when determining the performance of
other new microbiological diagnostic aids
Advantages

 Can obtain relative & absolute counts

of cultured species.

 It
is the only in vitro method to assess
antibiotic susceptibility of microbes.

 Gold standard
Disadvantages

• Can grow live bacteria only

• Requires strict sampling & transport conditions
•Error relating to adequacy of dispersal method,
no of dilutions, the plating method, length of
incubation, reliability of tests.
•Some pathogens are fastidious & difficult to
grow.
•Sensitivity is rather low.
•Time consuming & expensive
Direct Microscopy
•Alternative to culture Dark field / Phase
methods contrast microscopy
Electron microscope,
•Simple, non invasive & Confocal scanning
non expensive electron microscopy
•Ability to count all the
bacteria in the plaque
sample.
Limitations
1.Inability to determine
the relative susceptibility
to AMA.
2. Most of the pathogens
are non motile, hence
unable to detect them
 Health- cocci, non motile-rods.
 Gingivitis- motile rods and spirochaetes.
 Periodontitis- very large nuber of
spirochaetes
( Listgarten,slots)
Immunodiagnostic Methods
 Antibody–Antigen reaction can be
revealed by:

Immunofluorescent assay- direct

and indirect
 Flow cytometry
 Radio immunoassay
 ELISA
 Western blot
Latex agglutination.
 ELISA

 Itis the most widely used serological tests for

antibody or antigen detection.
 This test involves the linking of various label
enzymes to either antigens or antibodies.

 2 basic methods are used

Double antibody sandwich assay
Indirect immunosorbant assay.
Advantages Disadvantages

1. Very specific & 1.Not all pts affected

frequently used for with
detection of microbes demonstrate
periodontal increased
pathogens Ig levels

2. Used to monitor 2. Organisms like

antibody levels as they Capnocytophaga &
are 2.3-4.7 Treponema
times as sensitive as either don’t induce or
other may
immunological assays suppress immune
reactions
Evalusite
 This
chair side immunoassay detects periodontal
pathogens such as Aa, Pg, Pi.
 Principle: linkage between the antigen
and a memrane bound antibody to form
an immunocomplex that is later revealed
through a colorimetric reaction when a
colored enzyme substrate is added.
 Positive test forms a blue dot on the
reagent pad.
 Has a detection limit of 105 for Aa and 106
for pg.
 Radio Immuno Assay
 It was developed by Rosalzn Valow in 1977.

 Uses a purified antigen that is radioisotope-

labeled and competes for antibody with
unlabeled standard.
 The radioactivity associated with the antibody is
then detected by means of radioisotope analyzers
&
autoradiography.
 A large amount of bound radioactivity indicates
that there is little antigen present in the
experimental sample
 Enzymatic Methods

 BANA: It is an enzymatic assay for the identification of

trypsin like proteases

 The activity of this enzyme is measured by the

hydrolysis of the colourless substrate N-Benzyl-
Arginine-DL- 2 Napthylamide.
 When the hydrolysis takes place it releases the
chromophore-β-Naphthylamide which turns orange
red when fast garnet is added to the solution.
 Loesheet al in 1986-proposed the use of
BANA in subgingival samples

 Reported that shallow pockets exhibited

10% BANA positive reaction , where as
deeper pocket [7mm] were 70-90% BANA
positive.
 Perioscan
 Advantages

 Positive reaction- Indicator of presence of

pathogens strongly associated with disease
 When compared to culture, which cannot
identify T.d & T.f , this provides a rapid &
inexpensive method
 The BANA enzyme is stable & can be detected
in frozen plaque samples.
 Rapid chairside test with a result in 15 mins
Disadvantages
 It does not include inhibitors of host
proteinases which could contaminate the
plaque sample from saliva & GCF & which
also cleave the BANA substrate

 False positive results.

 Detects only 3 pathogens.

 Inability to determine which of the 3 bacteria

are responsible for the enzyme production

 Does not detect sites undergoing active

destruction
Nucleic Acid Probes
 These probes consists of nucleic acid sequences that
are labeled with a radioactive & enzymatic
calorimetric
marker that bind to complimentary nucleic acid
sequences
on corresponding micro organisms

 Commercially available kit “MicroDent” employs

probes for Pg, Aa, Tf, Td, &Pi. [Eick S Pfischer 2002]
The probes may be
1.Whole genomic probes
2.Randomly cloned probes
3.Oligonucleotide probes.(16SrRNA)
 Plaque sample

Denaturation of protein

Single bacterial DNA

Isolated on Nitrocellulose membrane

Incubation of DNA probe on membrane

Hybridization of the 2 DNA strands

 ADVANTAGES
 When compared to culture they have a sensitivity
of 96% & specificity of 86% for Aa & 60% & 82% for
Pg.
[Van Steenberghe]

 Problem of cross reactivity is overcome by

Oligonucleotide probes which have a sensitivity of
100% for A.a & Pi [Savitt. et.al] & 91% for Pg.
Omnigene / BTD

 Quantitative assessment of microbes.

 This DNA probe tests for A.a, P.g,

Prevotella intermedia, E.corrodens,
Fusobacterium nucleatum & C. rectus.

 Results are given as negative or low,

moderate, or high presence of the
targeted bacteria.
Technical problems with conventional
DNA probes [JISP 2004]

 The genetic material must be released from its

intracellular location

 Plaque enzyme can directly destroy DNA or RNA

& thus it has to be inhibited.

 Probe must have some type of marker or

reporter system that enables its detection

 Whole genomic probes require processing in lab

[ overcome by oligonucleotide probes]
 Cross reactivity of whole genomic
probes

 If more than one species involved,

many probes required

 Not developed for all microbes

Epsilomer Test [E-test]
 Itis the direct quantification of antimicrobial
susceptibility to microorganisms.
 A drop shaped inhibition zone intersects the test
strip at
the inhibitory concentration of the antibiotic.
[Nichani S et al]
 PCR

 It is a new nucleic acid based assay [Karv Mulli].

 Itcan detect a single micro-organism & has

therefore the highest sensitivity of any
microbiological method.
 Key to the PCR detection of DNA segments is the
selection of 2 DNA primers, usually synthetic
oligonucleotide of 18-23 bases length.

 Theseprimers are added to a solution containing

double stranded DNA from patient’s plaque
sample.
 DENATURATION
94-960

ANNEALING
ELONGATION 720
65O
 When the mixtures are heated to 90° - 95° it
denatures the newly created DNA strand from
the DNA template.

 Repeated cycles of denaturation, annealing &

extension, produce numerous copies of the DNA
segment & hence amplification of an original side
DNA to very large numbers of same sequence
results.
 End Point PCR- (ARBITRARY PCR) Obtains PCR product in saturated phase,

disregarding the early exponential phase. Therefore the amount of PCR product

obtained shows a weak correlation with the initial DNA quantity.

 Real time PCR- With this technology & by using a single copy of these genes per

cell, a good correlation between fluorescent signal measured & the no of cells

has been obtained.

 MULTIPLEX PCR-

This technique is an expansion of single target PCR methodology in which more

than one pair of species specific primers is used in a single PCR assay and that

permits multiple species to be detected simultaneously. Such assays have been

used to detect A. actinomycetemcomitans, T. forsythia and P. gingivalis at the

same time. Optimization of multiplex PCR can be laborious to establish, but

ultimately these assays are quite sensitive, with detection limits of 10–100 cells per

PCR reaction.

 The MicroDent Test (Hain Diagnostika Ltd., Nehren, Germany) is a commercially

available method using multiplex PCR that tests for five oral species and has

been used to compare the microbial profiles of subgingival plaque samples in

oral health and periodontitis.

CLINICAL STUDIES
Tests for treatment decisions
 Rosenberg et al- patients diagnosed with
aggressive periodontal therapy who did not
respond well to SRP, improved when they
were treated with selected antibiotics based
on the microbial testing.
 Ishikawa et al – reduction in Aa count and
improved clinical parameters following use of
antibiotics based on microbial testing.
Microbial tests for monitoring patients.
 For predicting the recurrence of
periodontal disease before the clinical
manifestations are apparent.
 Haffejee,Rams etal: sites with incresed
levels of Pg,Pi,Cr was correlated with 2.5
times increased risk for disease
recurrance.
SUMMARY
 Culture methods have been widely used in
characterizing the composition of the
subgingival microflora and are still considered
the gold standard.

 However, they have a number of

disadvantages.

 Direct microscopy has been of limited value in

identification of periodontal pathogens.
 Scientific progress at the end of the 20th century
particularly in the field of molecular biology has
led to advances in periodontal microbiology.
 DNA based methodology for the identification and
detection of specific bacteria and viruses offers
remarkable advantages in cost and time savings
compared to culture methods.

 The number of samples that can be examined and the

number of microorganisms enumerated have
increased dramatically.

 Perhaps even more relevant is the present ability to

detect microorganisms that cannot be cultivated thus
far, which has underscored the limitations of our
knowledge of this complex ecological niche.
Advances In Genetic Assessment

A new genetic susceptibility test

[Periodontal Susceptibility test, IL Genetics
Inc. Waltham.Mass]- Kornman &
Colleagues

 Detectsthe presence of a specific form of

2 IL genes; Allele 2 at IL1A+4845 &
IL1B+3954
 Test also used to correlate
the IL-1 production Other
clinical parameters; BOP,
Bone & attachment loss and
tooth & implant loss.

 Additional prospective
clinical trials are needed to
determine the risk of
developing periodontitis
 Advanced Diagnostic Aids In
Characterizing The Host Response
 Assessment of host response refers to the study of
mediators by immunologic or biochemical methods
that are recognized as part of the individual
response to the periodontal infection.

 To monitor & identify pts at risk for periodontitis.

 Early detection of pts at risk for disease
 Proper treatment intervention
 Decrease the need for aggressive treatment &
 Improve the response to periodontal therapy
 GCF
Electronic device, measures the change in the
capacitance Across the wetted strips & this change
is converted into a digital read out correlated with
GCF volume.

Periotron
 Saliva

 Proposed diagnostic markers in saliva-

 Proteins,
 Enzymes of host origin,
 Host cells,
 Hormones,
 Volatile compounds,
 Bacteria & its products, ions etc
 Potential markers have been studied.

 Host derived enzymes and their

inhibitors.
 Inflammatory mediators & host
response modifiers
 Tissue breakdown products
Host Derived Factors

HOST ENZYMES

PROTEOLYTIC HYDROLYTIC
ENZYMES ENZYMES

Collagenase
Elastase Aryl sulphatase
Cathepsin-B B-glucornidase
Cathepsin-G Alkaline Phosphatase
Cathepsin-D Acid Phosphatase
Dipeptidylpeptidases Myloperoxidase
Tryptase Lysozyme
Lactoferrin
Immune & Inflammatory Mediators

Immune response –
Antibody
Total IgG and IgG subgroup
Complement components

Inflammatory response –
Arachidonic acid derivatives – PGE2
Cytokines – IL-1, IL-2, IL-4, IL-6, TNF- α
 Tissue Break Down Products

Fibronectin: Cleaved components of fibronectin

Collagen: Hydroxy proline, collagen cross linkage

peptides, terminal peptides

Proteoglycan: GAGs

GAGs: Heparin sulphate, chondroitin-4-sulphate,

chrondroitin-6-sluphate
SPECIFIC & NON-SPECIFIC MARKERS IN SALIVA
Dr.(Prof) ANIRBAN CHATTERJEE
Dr.(Prof) ANIRBAN CHATTERJEE
Cytokines
Saliva: Potential cytokine marker in saliva is PAF
(platelet activation factor).Salivary PAF is
significantly higher in untreated chronic periodontitis
pts, correlate with clinical indices of disease severity
& also reduces following treatment. (Rasch et
al,Garito et al 1995)

GCF: IL-1β & TNF- α in GCF causes stimulation of

prostaglandin E2 & collagenase production -thus
most important in the pathogenesis of
periodontitis
PENTRAXIN-3
It is one of the mediators of inflammation
and they are the markers of acute phase
reactions.
Compared to healthy, gingivitis and
periodontitis patients, will have 2 fold and 3
fold respectively increase in pentraxin level.
-DR. PRADEEP A.R.
JCP 2011
 IL-1 &  are present in inflamed gingiva. [Honig et al 1989]
and the concentrations increase with severity and show
decrease in their levels following treatment.

 Levels of IL-6 and IL1 high in patients with refractory

periodontitis.
 TNF in GCF does not correlate with probing depth/ gingival
inflammation (Rossomando et al)
 Lee et al( longitudinal study): Levels of IL-1beta, IL-2,4,6 and
TNF-α might associate with but not predict the progressive
attachment loss.
 But in the same study in areas of bone loss, investigators found
increased levels of IL-2,6 and IL-1beta – suggested that these
markers may be predictive of future attachment loss in
refractory periodontitis.
 Since monoclonal antibodies have been
produced for these cytokines, they can
be measured by ELISA- thus potential for
use in diagnosis.

 Thelevel of predictive ability of these

cytokines is unclear.
 Prostaglandins

 GCF PGE2 levels are low in health.

 Increase in experimental gingivitis [b/n 32 & 53ng/ml]
& significantly higher in untreated periodontitis

 GCF PGE2 is predictive for periodontal disease

activity.
Levels greater than 66ng/ml - Predictive of further
possible
LOA with a sensitivity of 0.76 & specificity of 0.96 with a
overall predictive value of 0.92-0.95.
[Offenbacher S, Odle BM, Van Dyke TE, 1986]
 At present, the predictive ability of
cytokines is still in doubt .
 IL-1beta, IL-2 & IL-6 show some promise in
this regard, but with many limitations.
 Thus most likely diagnostic marker of the
inflammatory & immune factors is GCF
PGE2
 ADVANTAGES DISADVANTAGES
 GCF PGE2,has been
shown to be predictive  Choice of appropriate
of disease activity in marker is difficult.
longitudinal studies.  Which site to sample
and when to sample
 Rapid method and  Expensive.
simple to use.
 Un avilability of the
chair side kits.
 Facilitate
patient
motivation
Host Derived Enzymes
Collagenases & Related MMPs
[Neutral Proteinases]
 These are part of family of MMPs that degrade the
collagen

 Collagenase [MMP8 & MMP1] - present in GCF, saliva,

gingival tissue (INGMAN, UITTO et al)
 GCF collagenase activity is shown to increase with -
gingival inflammation & pocket depth & alveolar bone loss
& decreased post treatment. (Golub etal)

 No longitudinal studies of salivary MMPs-salivary samples

relate to whole oral cavity & are unable to give
information about the site related disease progression.
 Periocheck [AC tech]
 Thissystem (Pro Dentec Bates ville) detects the
presence of neutral proteinases such as collagenase
in GCF
 Theintensity & the area of blue color is
then scored on a scale of 0 -2 by
comparing it with 3 standards on a color
card provided with the test kit
Prognostik [Dentsply]
 It detects the presence of serine proteinase and
elastase in GCF samples.
 AFC (7-amino-trifluromethyl coumarin –peptidyl
derivative)

 Produces green fluorescence in the strip, which

can be seen under UV light using UV light box

 The intensity of the fluorescence is proportional to

the amount of elastase in sample & is scored by
comparing it with AFC standards
Commercial Tests Under Development
-glucuronidase: (Lamster and Page)

 A diagnostic kit based on ß- glucuronidase is being

commercially developed by Abbott Laboratories, North
Chicago, USA.

 It probably uses a histochemical substrate for the

enzyme coupled to a colour detection system which is
released if the enzyme attacks the substrate.
Commercial Diagnostic Tests For
Elastase

BIOLISE

 Recently a software has been made Biolise

[SLT-Lab
instruments, Craitsheim, Germany] which is used
to detect the elastase activity in GCF.
[Hermann et al 2001].
 Procedure
 First
collect the GCF in test tubes.
 Test tubes containing GCF and sample buffer or
elastase standards are centrifuged at 5000 rpm.
 Then 10l of this volume is pipetted into a microliter
plate containing 90l assay buffer (pH-8.1).
 Afterwards 50l of a solution of the fluoregenic
substrate is covered with a removable film and
incubated for 6 hours at 25 0C.
 Then elastase activity of the sample is directly
calculated using Biolise.
 TOPAS TM
A new TOPAS [Toxicity Prescreening
Assay] test kit has been introduced to
detect two markers of infection:
 Increased levels of bacterial toxins.
 Increased levels of human inflammatory
proteins & bacterial proteins.
 It is a simple, painless test [ 7 min] at a very
reasonable cost.
 There are two generations of this test.
 Manual
 Automated version.
 Principle
 TOPAS is based on the reaction of bacterial
toxins in GCF with a specially developed mixture
of chemical reagents to produce a dose related
color change.
 The greater the concentration of toxins in the
GCF sample, the brighter the yellow color of the
assay mixture
Bacterial toxins
Inflammatory proteins
Cysteine & Serine Proteinases
A test system suitable for chair side use has been
developed by Enzyme System Products/ Prototek of
Dublin,California, USA.
 It detects proteinases like-
• Serine proteinases,
• Elastase – Kennett , Eley and Cox (predictive of
future attchment loss)
• Tryptase ( Jeffcoat, Eley and cox)
• DPP II, IV
 Cathepsins B & L.- Cathepsin B good
predictor of future progressive atachment
loss.(Cox and Eley)

 This system contains the peptide

substrates & AFC( amino tri flouromethyl
comarin) leaving group which is
considerably more sensitive than other
fluorogenic leaving groups.
The intensity of the fluorescence is detected under UV light and
is proportional to the amount of enzyme in the sample.

Colour detection is done by adding cinnamaldehyde to the

well - forms a coloured Schiff reagent.
Enzymes Released By Dead Cells
[Cytosolic Enzymes]

AST & LDH

 GCF AST levels is related to confirmed attachment loss

and are strongly associated with disease active sites than
inactive sites. ( Persson et al)

 LDH- correlated with probing depth & other clinical

indices of disease activity. ( Lamster et al)

A commercial diagnostic test kit has been developed &

marketed as PerioGard
 Periogard [Colgate] AST in GCF test kit
 Test kit uses paper point GCF samples with
colorimetric
detection.
 Reagent [10mM Tris HCL with 0.067% Triton X100, Ph
6.0]
 A color of greater intensity than the negative control
is
scored as positive(800U) and lesser /equal intensity as
negative result.
Pocket WatchTM [Periodontal Tissue
Monitor System] ( Shimhadaka K, Mizuno T.
1990)
 An in-vitro diagnostic test kit PocketWatchTM [Steri-Oss
Inc, Yorba Linda, CA, USA] has been developed to analyze
the AST levels in GCF at chair side.

 The Pocket Watch detects elevated levels (>1200IU) of

AST in GCF and is used as an objective, biochemical test
for diagnosing & monitoring the disease activity, to
determine
when to treat, and also to evaluate the treatment
effectiveness.
Advantages Disadvantages

• Simple to use • The appropriate

biomarker may still be
difficult at the present
• Can be read in state of knowledge.
relatively short
periods
• There may be difficulty in
• Can be shown to the determining the sites to
patient & related to sample
the tooth site • No amount of biological
affected. control mechanisms is
taken in present tests.
• Cost
LAB ON CHIP “ NEW BREAK THROUGH”
(developed by sanadia laboraries for
dentistry in 2007)
DIPSTICK
GLUCOMETER
CHAIR SIDE TOOL
ELUSITE FOR P.GINGIVALIS
VIZILITE PLUS FOR ORAL CANCER
 MARKERS OF BONE RESORPTION

The components of bone that could be released

during bone resorption & are present in GCF
are known as bone specific proteins.
They are
1. Osteonectin
2. Bone phosphoprotein (N-propeptide)
3. Osteocalcin
4. Telopeptides of type1 collagen.
Sampling & detection

 Osteonectin in GCF – Nitrocellulose strip

 Osteocalcin - conventional paper strip for 30
secs. or multiple collection for 1min at same site

Diagnostic tests:

 Detection by specific monoclonal or polyclonal

antibodies - ELISA
 Osteocalcin - ELISA (Nakashima1994) &
radioimmunoassay (Giannobile., 1995)
 Osteonectin & N-propeptide – ELISA (Bowers.et.al
1989)
 CONCLUSION:
Alkaline phosphatase, beta-glucuronidase,
cathepsin B,collagenase-2 (MMP-8) and gelatinase
(MMP-9),elastase and dipeptidyl peptidases II and IV
may have a potential diagnostic utility for treatment
planning and for monitoring treated patients

In addition, cathepsin B, collagenase-2 (MMP-8),

dipeptidylpeptidases II and IV, and elastase seem
promising for distinguishing periodontitis from
gingivitis

For most molecular markers, it seems that elevated

levels are merely a reflection of the inflammatory
state.
 Today, no single or combination of GCF markers
is available to determine whether periodontal
treatment is sufficient & ⁄ or necessary to prevent
further periodontal breakdown.

 Some of the tissue breakdown products are the

most promising potential GCF markers of disease
progression especially those that degrade the
bone.

 Futureresearch on these bone markers will

provide promising results
 CONCLUSION
 In most of the cases traditional diagnostic tests are sufficient
to diagnose the specific disease but some cases which are
refractory and do not respond well to the planned treatment
modalities may require specialised/ advanced diagnostic
tests.

 Some of these new technologies will address the part of the

diagnostic dilemmas of the periodontists and some of it will
not.Science and common sense are required to distinguish
between hype and truth and between promise and
performance.

 Gathering more information simply because we have the

capability to do so does not make any sense and nor it
automatically translates into better treatment for improved
patient out come unless they are properly understood and
applied by the clinician.
 Bibliography
 Carranza’s Clinical Periodontology: 10th edition

 Wilson and Kornman: Fundamentals & advances in

periodontics.

 White & Pharoah: Oral Radiology Principles and Interpretation.

4th Edition. 2000.

 Perio 2000: vol 7:1995: Diagnostic techniques in

periodontology.

 Outline of periodontics, 4th Edition; Manson & Eley

 Greenstein G,HART. C.T. Clinical utility of a genetic susceptibility
test for severe chronic periodontitis: A critical evaluation. JADA. Vol
133: April 2002;452-459

 Advances in periodontal diagnosis, British Dental Journal

1998;184:12-16, 220-223,323-328,373-376,427-430,489-492

 A new checkerboard panel for testing bacterial markers in

periodontal
disease.( Dahlen.G.Leonhardt, OM&I, 2006)

 Host-derived diagnostic markers for periodontitis: do they exist in

gingival crevice fluid? Perio 2000: vol 39; 2005,53-72
DNA PROBE: Application in periodontics (Dr. Amit agarwal, JISP,
2004,ISSUE 3)

Analysis of host response and risk for disease progression . Perio

2000: vol 34:57-83

 Imaging methods in periodontology . Perio 2000: vol 34 : 34-48

 Tooth mobility revisited ( Charles R, Anderegg & David) J

Periodontol July 2001: 963-967

 The clinical value of salivary biomarkers for periodontal

disease. Perio 2000, vol 51,2009,25-37.
“DIAGNOSIS IS NOT THE END BUT THE
BEGINNING OF THE PRACTICE”
- DR. MARTIN H.FISCHER
Dr.(Prof) ANIRBAN CHATTERJEE