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Published by Hafizi Ali, 2019-09-10 02:50:51

Periodontics handbook

Periodontics handbook

DENT 3426|DENT 4426|DENT 5426

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Workstation: PER
Version no: 2
Revision no: 4
Effective date: 1st Sept 2019

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TABLE OF CONTENTS

Introduction....................................................................................................................................... 1
General Objectives .......................................................................................................................... 2
Course module: Year 3 (DENT 3426)...................................................................................... 3
Course module: Year 4 (DENT 4426)...................................................................................... 4
Course module: Year 5 (DENT 5426)...................................................................................... 5
Assessment system......................................................................................................................... 6
List of lectures for 2019/2020................................................................................................... 7
Outline of competencies after completion of Periodontology course .....................10
A glance on periodontal examination and diagnosis......................................................14

Biographic and demographic information.....................................................................14
Patient examination: ...............................................................................................................14
Patient complaint: ....................................................................................................................14
Medical history:.........................................................................................................................14
Dental history: ...........................................................................................................................14
Social history/family history:..............................................................................................14
Plaque control history:...........................................................................................................15
Extraoral examination:...........................................................................................................15
Intraoral examination:............................................................................................................15
Full periodontal charting.......................................................................................................16
Clinical indices:..........................................................................................................................16
Basic periodontal examination (BPE) 2019 ..................................................................17
The Gingival Index GI (Loe and Silness, 1963).............................................................19
Bleeding on probing (BOP) (Greenstein 1984)............................................................20
Plaque index (PI) (Silness & Loe, 1964)..........................................................................20
Plaque Control Record (the O'Leary Index)...................................................................21
Full periodontal charting / assessment ...............................................................................21
Probing depth measurement:..............................................................................................21
Periodontal Probing Depth (PPD) or probing depth (PD): .....................................22
Gingival recession: ...................................................................................................................23
Clinical Attachment Level (CAL): .......................................................................................24
Mobility:........................................................................................................................................26
Furcation Involvement:..........................................................................................................27
Radiographic survey: ..............................................................................................................28
Treatment planning......................................................................................................................28
Sequence of treatment ................................................................................................................29

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Phase I therapy: Non-Surgical Periodontal Therapy/Initial periodontal
Therapy/ initial Hygienic phase.........................................................................................30
Phase II therapy: Surgical or corrective therapy.........................................................30
Phase III therapy: Supportive periodontal therapy (SPT)/Maintenance
therapy ..........................................................................................................................................30
Fundamental of Instrumentation.......................................................................................32
General principles of instrumentation.............................................................................32
Reference books for periodontology course......................................................................37
Annex A: Staging and Grading of 2017 Periodontitis Classifications.......................38
Annex B: Rubrics for periodontics clinic .............................................................................40
A) Rubrics for the assessment of calculus removal post scaling (for Year 3) .40
B) Rubrics for the assessment of root surface debridement (for Year 4).........41
C) Rubrics for scaling competency test ...........................................................................50

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List of Tables

Table 1. Marking scale for clinical works .................................................................... 6
Table 2. Professional Examination IV Weigthages .................................................. 6
Table 3. List of Lectures- Year 3, Year 4 and Year 5................................................ 7
Table 4. Scores for Gingival Index (G.I) ......................................................................19
Table 5. Bleeding on Probing Score.............................................................................20
Table 6. Plaque Index ........................................................................................................20
Table 7. Plaque Control Record.....................................................................................21
Table 8. Clinical Requirement for Year 3...................................................................33
Table 9. Clinical Requirement for Year 4 and Year 5...........................................34
Table 10. Rubrics for the assessment of calculus removal post scaling (for
Year 3).....................................................................................................................................40
Table 11. Rubrics for the assessment of root surface debridement (for Year
4) ...............................................................................................................................................41
Table 12. Rubric for Scaling Test ..................................................................................50

List of Figures

Figure 1. Basic Periodontal Examination (BPE) .....................................................17
Figure 2. Interpretation of Basic Periodontal Examination (BPE) ..................18
Figure 3. Six Sites for Probing........................................................................................22
Figure 4. Walking Probe...................................................................................................22
Figure 5. A: The Sulcus, B: The PPD of 2mm ............................................................23
Figure 6. Recession Type (RT) according to Cairo 2011. A: RT1. B: RT2, C:
RT3 ...........................................................................................................................................23
Figure 7. Examination of Mobility Using Two Instruments ...............................26
Figure 8. Examination of Mobility Using One Instrument and One Finger ..26
Figure 9. Naber's Probe....................................................................................................27
Figure 10. Grading of Furcation Involvement. A: Grade 1, B: Grade 2, C:
Grade 3....................................................................................................................................27
Figure 11.Sequence of Periodontal Treatment .......................................................29

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Introduction

Periodontology is one of the subjects that are designed by the periodontics
department, school of dentistry, IIUM. Starting in year three the
periodontology course is designed to give students a thorough knowledge in
the normal anatomy of periodontium and the basic principles of the etiology
and epidemiology, as well as the progression and pathogenesis of periodontal
diseases. In this year the course provides relevant information about the initial
therapy and oral hygiene instructions through demonstration sessions carried
out to enable the dental students to learn the instrumentation in periodontics
and the scaling procedures. The practical sessions progress the students’ skills
to gain expertise in examining, charting the oral health status of patients and
conduct the initial procedures (scaling, polishing and prophylaxis) in which the
crown and root surfaces of the teeth are instrumented to remove the calculus,
plaque, accumulated materials and stains.

In year four the knowledge learned on the previous year are applied in more
complicated clinical cases. In particular; students are encouraged to formulate
a sequenced treatment plan and maintaining a stable periodontium through
the applied recall and reevaluation protocols.
In the final year the students are required to carry out different treatment
modalities and therapeutic and preventive measures in the field of
periodontology under the supervision of periodontics senior members and
must also be able to discuss the rationale behind surgical periodontal
procedures by assisting during surgeries.

The Assessment and evaluation of the students’ cases and requirements
achieved through the continuous assessment, clinical presentations and
examinations. All clinical subjects supported by detailed theoretical lectures.
Students are expected to maintain a high level of professionalism throughout
their periodontal clinical experiences. This includes treatment of their patients

1

in a timely and orderly manner. Students have responsibility for continual care
and evaluation. Failure to follow through with timely care for patients may
affect the student’s periodontal clinical grade.

General Objectives

1. Providing fresh perceptions on clinical key topics, throughout this course
that deals with the most up to date coverage of the comprehensive clinical
periodontal field.

2. Guiding the dental students to understand how knowledge in various
spectrums of this discipline was progressed and how it should be used in
the practice of dentistry.

3. To gain clinical competency in diagnosis, treatment plan, and the principles
of prognosis of the periodontally involved patient, gathering the skills
required to effectively perform a patient assessment.

4. Utilizing broad knowledge in treating and preventing periodontal
pathologies by reducing microbial challenge to the host through closed or
opened techniques using manual and powered instrumentation, preceded
by performing a thorough dental prophylaxis.

5. Learning ethical practice and the communication abilities, through
respecting patient's rights.

6. Learning basic concepts of implant dentistry.

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Course module: Year 3 (DENT 3426)

Teaching method(s): Didactic and clinical
Lecturer(s): Dr Mohd Nor Hafizi, Dr Juzaily, Dr Munirah, Dr Suhaila

The course was designed to introduce students to principles of examination,
consultation, instrumentation, etiology, pathogenesis and progression of
periodontal disease, non-surgical therapy and to emphasize the importance of
maintenance in the periodontal patient. Clinical, histopathologic and
radiographic features of periodontal diseases are presented. Students are
exposed to clinical experience in examination, preventive periodontics,
instrumentation, treatment planning and initial therapy of periodontal disease.

Learning outcomes:

On successful completion of this module, students should be able to:
1. Explain the clinical significance of the structures and functions of the
periodontium.
2. Explain the epidemiology, etiology, pathogenesis, diagnosis, prognosis
and treatment plan of periodontal diseases.
3. Explain the impact of periodontal conditions on the systemic health.
4. Display appropriate skills for periodontal clinical examination and
therapy/scaling.

Assessment: continuous clinical assessment at clinics, formative assessment
Formal written examination: Mid-Year Exam & Quizzes during block 4
Clinical Requirements for Year 3: please find the Appendix.
Eligibility for Year 4: completed Y3 clinical requirements and pass the

Examination & Diagnosis test (E&D test).

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Course module: Year 4 (DENT 4426)

Teaching method(s): Didactic and clinical
Lecturer(s): Dr Mohd Nor Hafizi, Dr Juzaily, Dr Munirah, Dr Suhaila

The principles learned earlier are applied in more complicated clinical cases. In
particular; students are encouraged to link periodontics and the other dental
disciples in the fields for treatment planning and organization of patient care.

Learning outcomes: On successful completion of this module, students

should be able to:
1. Explain the basic principles of periodontal surgery.
2. Demonstrate non-surgical therapy for mild to moderate periodontal

disease.
3. Infer the results of periodontal treatment.
4. Describe the basic principles of dental implant and the associated peri-

implant diseases.

Assessment: continuous clinical assessment at clinics, case presentation and

formative assessment.

Formal written examination: Mid-Year exam & Year-End Exam
Clinical Requirements for Year 4: please find the Appendix
Eligibility for Year 5: completed Y3 & Y4 clinical requirements and pass the

Examination & Diagnosis test (E&D test).

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Course module: Year 5 (DENT 5426)

Teaching method(s): Didactic and clinical
Lecturer(s): Dr Mohd Nor Hafizi, Dr Juzaily, Dr Munirah, Dr Suhaila

In the final year a variety of learning activities have been incorporated such as
case presentation, evidence-based literature reviews, link between periodontal
cases and other fields of dentistry.

Learning outcomes: On successful completion of this module, students

should be able to:
1. Perform supragingival and subgingival scaling and root surface
debridement, using both powered and manual instrumentation.
2. Demonstrate the different periodontal treatment modalities in relation to
other dental disciplines.
3. Explain the need for the indications and contraindications for the
advanced surgical technique.
4. Construct patients’ supportive program.
5. Display skills in managing the periodontal conditions according to the risk
assessment.
6. Organize the appropriate referral based on the assessment

Assessment: continuous clinical assessment at clinics, case presentation and

formative assessment.

Formal written examination: Pre-Professional exam (Pre-PRO) and

Professional exam IV

Clinical Requirements for Year 5: please find the Appendix
Eligibility for Professional exam IV: completed the clinical requirements

for Y3, Y4 and Y5 and pass the scaling competency test.

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Assessment system

Table 1. Marking scale for clinical works

Marking scale for clinical works (Clinical assessment book)

Marks Description

1 to 4 Below average skills, professional attitude, patient management and personal
5 to 6 organization.
Average or marginal performance skills, professional attitude, patient

management and personal organization.

7 to 8 Good skills, attitude, patient management and personal organization

9 to 10 Outstanding/excellent skills, professional attitude, patient management skills
and personal organization.

Year Summative Exams for Periodontics

Y3 Mid-Year examination
Quizzes

Y4 Mid-Year examination
Year End examination

Y5 Mid-Year Examination
Professional Examination IV

Table 2. Professional Examination IV Weigthages

Professional Examination IV weightage

Continuous Assessment from Year 3 till Year 5 40%

(EOB’s, clinical performance, case presentations, quizzes

and seminars)

Professional Examination: Theory and OSCE 60 %

Total 100%

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List of lectures for 2019/2020

Table 3. List of Lectures- Year 3, Year 4 and Year 5

YEAR 3

Blocks Topics

Introduction to Basic Periodontology

Theme: Functional anatomy of the periodontium:

A. Gingiva

B. Cementum and periodontal ligament

C. Bone
1 Classification and epidemiology of the periodontal diseases

Theme: Aetiology of the periodontal diseases

A. Periodontal Microbiology

B. Periodontal pathogenesis
i. Clinical and histopathological features of the periodontal diseases
ii. Host parasite interaction

Theme: Modifying factors

A. Local contributing factors
2 B. Systemic contributing factors

C. Smoking and periodontal diseases

D. Genetic factors and periodontal diseases

Theme: Periodontal pathology
A. Healthy periodontium and plaque-induced gingival disease

B. Non-Plaque-induced gingival disease
3

C. Periodontitis-1

D. Periodontitis-2

E. Others condition affecting periodontium

Theme: Examination
A. Examination, investigation and periodontal recording of patients with periodontal

disease
4 B. Radiographic interpretation in the diagnosis of periodontal disease

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C. Determination of treatment planning, periodontal diagnosis, prognosis & risk
assessment
Tutorial

YEAR 4

Blocks Topics

Theme: Initial periodontal therapy

A. Non-surgical periodontal therapy (NSPT)

B. Motivation

C. Mechanical plaque control

1 D. Manual versus ultrasonic instrumentation

E. Chemical plaque control

F. Antibiotics in periodontal therapy

G. Periodontal treatment of the medically compromised patients

Tutorial 1: Initial Periodontal therapy

Theme: Periodontal surgical therapy

A. Principles of periodontal surgery I

B. Principles of periodontal surgery II
2 Theme: Advanced surgical techniques

A. Resective osseus Surgery

B. Periodontal regeneration

C. Mucogingival Surgery

Tutorial 2: Periodontal Surgical Therapy & Advanced Surgical Techniques

Tutorial 3: Mid Year Examination Feedback
Supportive periodontal therapy

3 Periodontics and implantology
Peri-implant diseases

New advance in periodontics

Case presentation
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Tutorial 4: Supportive periodontal therapy & Implantology

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YEAR 5

Blocks Topics

Problem Based Learning 1

1 Seminar 1: Recession and dentinal hypersensitivity.

Seminar 2: Geriatric and periodontics

2 Problem Based Learning 2
Seminar 3: Functional anatomy of periodontium and its clinical application

Seminar 4: Aetiology and modifying factors in periodontal disease

Problem Based Learning 3

Seminar 5: Periodontal diagnosis: gingivitis and periodontitis

Seminar 6: Periodontal Emergencies
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Case Presentation

4 Problem Based Learning 4
Seminar 7: Periodontal disease management in General Dental Practice.

Seminar 8: Advance periodontal treatment in General Dental Practice
Case Presentation

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Outline of competencies after completion of Periodontology course

1. Examination of periodontal compromised patients
Students should be able to interpret patient data regarding his medical
and dental history to accurately assess and treat the patients.
▪ A thorough periodontal examination is a critically important
data-collection activity that is necessary to arrive at a diagnosis
and develop a treatment plan. Prior to conducting the hands-on
examination, the information gathering process beings with
taking medical and dental histories from the patients.
● Medical history
● Dental history
● Periodontal charting

2. Radiographic evaluation of the periodontium
Students should recognize and identify the radiographic findings.
▪ The radiograph is a valuable aid in the diagnosis of periodontal
disease, determination of the prognosis, and evaluation of the
outcome of treatment. However, it is an adjunct to the clinical
examination, not a substitute for it.

3. Determination of prognosis
Students should achieve the ability to predict the outcome of
periodontal therapy.
▪ The term prognosis has been used to indicate the prediction of
the future course of a disease in terms of disease outcomes
following its onset and /or treatment. That’s including
evaluating the short- and long-term prognosis of both the
individual tooth and the overall dentition.

4. Determination of periodontal diagnosis
The students will formulate a comprehensive diagnosis using the
current terminology and 2017 classification of periodontal diseases
▪ To diagnose periodontal disease, one must have a classification
system with which to work. In 2017 the World Workshop on the
Classification of Periodontal and Peri-implant Diseases and
Condition coordinated by American Academy of Periodontology
(AAP) and the European Federation of Periodontology (EFP) had
proposed a new classification scheme for periodontal and peri-
implant diseases and conditions that is necessary for clinicians

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to properly diagnose and treat patients as well as for scientists
to investigate the etiology, pathogenesis, natural history, and
treatment of diseases and conditions. The new 2017
classification should be applied in the making of diagnosis for
new periodontal patients.
▪ Other non-periodontal diagnosis should also be included in the
diagnoses according to priority of treatment.

5. Treatment Planning
Students should be able to outline comprehensive periodontal
treatment plan as the blueprint for case management. The aims of
treatment plan to achieve healthy periodontal foundation for the
future rather than simply to salvage those teeth that were affected in
the past.
▪ The treatment plan is the road map for case management. It
includes all procedures required for the establishment and
maintenance of oral health. Treatment planning should include
all phases of periodontal therapy and other dental treatment
required by patients.
▪ Each diagnosis (es) requires treatment must be outlined in the
treatment plan.

6. Prevention of periodontal disease
Students should be able to evaluate the patient’s oral hygiene status
during all phases of periodontal therapy and give proper oral hygiene
regimes and develop an environment that the patient and the dentist
can maintain in a stable status with ease.
▪ It is quite clear that dental plaque is the cause of the problem
and its elimination will prevent periodontal disease. The key to
prevention is regular and thorough plaque removal, therefore
oral hygiene instructions is probably the most useful advice you
can give to your patients.
▪ Smoking exacerbates periodontal disease and adversely affects
treatment outcome. Smoking cessation advice should be given
to patient.

7. Treatment of periodontal emergencies
Students should be able to assess and treat the periodontal emergencies.
The periodontal emergencies include the treatment for acute periodontal
abscess.

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8. Phase 1 therapy: Non-surgical periodontal therapy (NSPT)
Students should understand the aims, be to plan and deliver the NSPT for
periodontally compromised patients. The NSPT phase is principally
designed to control and prevention of periodontal infection. The
treatments may include; supra and subgingival scaling and root surface
debridement (RSD).

They are also expected to be able to identify and refer medically
compromised patients to respective medical personnel if deemed
necessary prior to periodontal treatment.

9. Phase 2 therapy: Corrective phase of periodontal therapy (surgical)
Students should be able to identify and describe the periodontal disease
cases that require different surgical intervention for the management of
the disease.

They need to be able to describe the surgical methods and evaluate them
based on their potential to facilitate removal of subgingival deposits and
self-performed plaque control and thereby enhance the long-term
preservation of the periodontium. The corrective phase is designed
principally to restore function and, where relevant, aesthetics.

10. Phase 3 therapy: Maintenance phase of periodontal therapy
(supportive)

Students should be able to outline the necessary follow-up time based on
the assessment of the risk factors and outcome after Phase 1 or Phase 2
therapy.

The maintenance (supportive) phase aims to reinforce patient motivation
so that their oral hygiene is adequate to prevent recurrence of disease. This
phase is receiving increased attention due to the relative ease with which
disease activity can be monitored by probing and chair side diagnostic
assays.

11. Review visits post NSPT
Students require to show ability to analyze the patient’s current OHI
practice, relates with the plaque control record achievement to motivates
and prescribe proper OH regime to suit the patient’s needs. They should be
able to identify the necessity for regular review visit(s) based on the above
information and assessment.

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Review visit should be done at least 2 – 4 weeks after completed scaling or
RSD. Review visits aims to having patient’s feedback regarding:
● Latest oral hygiene practice and compliance after OH advised given by a

student.
● Complication after previous dental visits (especially after scaling and

RSD)
● To review the improvement by reviewing patient’s plaque control using

an O’Leary plaque score
● To reinforce the OHI
● If needed to deliver necessary treatment: re-scaling

12. Re-evaluation/Re-assessment visits
Student should be able to assess patient’s treatment outcomes by comparing the re-
evaluation data with the baseline data to formulate the need for further treatment or
re-treatment or maintenance visits, or the need for referral to a periodontist (for
corrective therapy/periodontal surgery) and other specialties or discharged patient
from periodontal clinic (for example in gingivitis cases).

During re-assessment, student is expected to update patient’s current
complaint/periodontal & oral health status, including noting any changes in the
medical history since treatment was started in comparison with the previous
history. An O'Leary plaque score must be accurately recorded. Student has to
re-chart patient's probing depths, furcation involvements, mobility index and
areas of recession as well as re-assess the prognosis and diagnosis of patient.

Revaluation/reassessment visit can be done the earliest at 6 to 8 weeks after
completed scaling or RSD.

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A glance on periodontal examination and diagnosis

Biographic and demographic information
Patient identification including names, date of birth (to determine age), gender
and registration number are very important for medico-legal and case note
identification.

Patient examination:
The clinical examination includes the history of the chief complaint, the
patient’s medical-dental-social history, and examination of the extraoral and
intraoral soft tissue.

Patient complaint:
Should be addressed accordingly. Further history of the complaints should be
sought from patients to help in determination of the diagnosis. Common
periodontal related complaints such as bleeding on tooth brushing, drifting
teeth, gum pain, teeth mobility gum swelling and etc. If there are other dental
complaints these should be noted.

Medical history:
Most of the medical history is obtained at the first visit and can be
supplemented by pertinent questioning at subsequent visits. Medical history
must be updated regularly on each dental visit(s).

Dental history:
Taking and recording a dental history is an extremely important aspect of
examination, diagnosis, prognosis, and treatment planning. Because more than
one dentist treats one patient, this history should be updated regularly. Past
experience and nature of the dental work including restorative and others
should be noted and the reason for any extraction should be asked. The
pattern of attendance for dental attendance is useful to be noted, which may
indicate compliance. Past history of periodontal treatment such as scaling and
root planing will assist further treatment planning.

Social history/family history:
A summary of any personal circumstances that may influence dental
management treatment provision, as such:

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> Motivation and compliance: patient’s nature of work, lifestyle, marital/social
status, familial disease
> Smoking status: It is a risk factor for periodontal disease. History of smoking
should be sought on the: duration of smoking, number of cigarettes consumed
and any attempt to stop smoking and nicotine dependence; also, smokeless
tobacco habits.
> Alcohol consumption and number of units
> Any familial hereditary of periodontal disease.
> Dietary factors relevant to caries risk.

Plaque control history:
A history of plaque control is important to be established during the
examination of a new or recall patient. Current plaque control status during
the examination depending on what is the patient’s current OH practice, how
compliance the patient to student’s OH advised to control the plaque
accumulation.

Extraoral examination:
Inspection of the extra-oral require before proceeding to the intraoral. The
brief assessments include facial symmetrical, mouth opening, lymph nodes
examination and TMJ examination.

Intraoral examination:
Student should use appropriate scientific terms to describe the condition of

the
gingiva. Student must elicit the areas of gingival health, inflammation, stippling
and recession. They should be able to show a clear understanding of the
patient’s periodontal condition. Other intraoral examination that should be
performed include:

o Examination of soft tissue of the mouth including mucosa, palate,
tongue

o Examination of hard tissue of the mouth including teeth and bone
o Specific examination of complained site with details description
o Fremitus
o Occlusal analysis (if deemed necessary)

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Full periodontal charting
Full periodontal charting is indicated when the patient found to has BPE code
‘4’ at least at one sextant. The full periodontal charting for
periodontitis/mucogingival cases should include the charting of the following
periodontal health parameters;
o Periodontal Probing depth (PPD)
o Recession (R)
o Clinical Attachment Level Loss (CAL)
o Mobility (M)
o Furcation involvement (FI)
o Clinical indices such O’Leary’s plaque score, Bleeding on probing (BOP)
o Gingival index and Plaque index (if deemed necessary)

In the charting of gingivitis cases, the following periodontal parameters should
be examined:

o Plaque index (PI)
o Bleeding on probing (BOP)
o Gingival index (GI)
o O’Leary’s plaque score (PS)

When presenting the case to clinic supervisor, student should ensure that all
periodontal parameters charted, calculated and completed prior to O’leary
plaque score examination. The reason for O’Leary plaque scores should be
presented later for clear inspection of the gingival condition.

Clinical indices:
The original purpose of periodontal indices is to study the extent of the disease
within the population group. Periodontal screening provides a quick and easy
method of detecting periodontal disease. It can summarize the necessary
information with minimal documentation. It may help determine patients who
would benefit from a more detailed periodontal examination and who may
require more complex periodontal therapy.

Each patient attending periodontal clinic should undergone Basic Periodontal
Examination (BPE) to give the initial impression of the treatment needed for
them.

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Basic periodontal examination (BPE) 2019

Figure 1. Basic Periodontal Examination (BPE)

17

Figure 2. Interpretation of Basic Periodontal Examination (BPE)

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The Gingival Index GI (Loe and Silness, 1963)

This index provides an assessment of gingival inflammatory status that can be
used in practice to compare gingival health before and after Phase I therapy or
before and after surgical therapy. It can also be used to compare gingival status
at recall visits. According to this method, each of the four gingival areas of the
tooth (facial, mesial, distal, and lingual) is assessed for inflammation and given
a score from 0 to 3.

Technique: Bleeding is assessed by running a periodontal probe along the soft
tissue wall of the gingival crevice.

Calculation of the scores: four areas of the tooth are totaled and divided by
four to give a tooth score. Adding all tooth scores together and dividing by the
number of teeth examined to obtain an individual's GI score.

Interpretation of GI score: 0.1 to 1.0 indicates mild inflammation, 1.1 to 2.0
indicates moderate inflammation, and 2.1 to 3.0 indicates severe
inflammation.

Table 4. Scores for Gingival Index (G.I)

Number Description

0 Normal gingiva

1 Mild inflammation: slight change in color and edema. No bleeding on
probing

2 Moderate inflammation: redness, edema and glazing, bleeding on
probing

3 Severe inflammation: marked redness and edema, ulceration,
spontaneous bleeding

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Bleeding on probing (BOP) (Greenstein 1984)

Technique: A blunt periodontal probe is inserted to the bottom of the gingival
pocket and is moved gently along the tooth (root) surface.

Calculation of the scores: The mean score is given as a percentage (%) figure
(the number of sites with gingival bleeding on probing divided by the total
number of sites per mouth, multiplied by 100).

This charting during the course of therapy will indicate the sites that turn
healthy or remain inflamed.

Table 5. Bleeding on Probing Score Description

Number

0 Absence of bleeding after insertion of probe (10 sec.)

1 Present of bleeding after insertion of periodontal probe (10 sec.)

Plaque index (PI) (Silness & Loe, 1964)
Calculation of the scores: Each of the four surfaces of each tooth was given a
score from 0-3, scores from these four surfaces were added together and
divided by four in order to give the average plaque index for each tooth, then
the records of each tooth were added together and divided by teeth number
for each patient to give the average plaque index for that patient.

Table 6. Plaque Index

Number Description
0 No plaque

1 Minimal plaque, only detected at the tip of the explorer after passing
it at the sulcus.

2 Plaque visually detected at the cervical part of the crown. Does not
exceed third of the crown.

3 Abundant plaque covering more than third of the crown.

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Plaque Control Record (the O'Leary Index)

O’Leary plaque score should be performed after complete presentation of
other periodontal parameters. The reason for O’Leary plaque scores should be
presented later for clear inspection of the gingival condition before staining
with disclosing solution.

Technique: Disclosing solution is applied to all supragingival tooth surfaces.
After the patient has rinsed to remove excess dye, each tooth surface (except
occlusal surfaces) is examined for the presence or absence of stained deposits
at the dentogingival junction, four surfaces for each tooth.

Calculation of the scores: After all teeth have been scored, the index is
calculated by dividing the number of surfaces with plaque by the total number
of surfaces scored and then multiplied by 100 to get a percentage of surfaces
with plaque present. A reasonable goal for patients is 10% or fewer surfaces
with plaque, unless plaque is always present in the same areas.

Table 7. Plaque Control Record Description

Number

0 Absence of visual plaque

1 Present of visual plaque

Full periodontal charting / assessment

Probing depth measurement:
Probing refers to the gentle use of a thin metal or plastic ruler, known as a
periodontal probe, to identify the level of the junctional epithelial attachment
on a tooth surface.
Probing gains insight into soft tissues, presence of bleeding, bone loss, bone
architecture, presence of calculus, furcation involvement, and root anatomy.

Generally, six areas are recorded for each tooth in a periodontal charting.
These areas include mesiobuccal, mid-buccal, distobuccal, distolingual, mid-
lingual, and mesiolingual measurements. The deepest measurement from each
area should be recorded.

21

Appropriate probing pressure should be 25 g. Because a scale for
measurement is not generally present, 25 g of pressure generally equates to
the pressure needed to depress the pad of the thumb 1–2 mm.

Walking probing / circumferential probing technique:
1. The probe is inserted gently into the gingival sulcus and should be kept
as close as possible to the axial direction of the tooth. Walking probing
should be used to ensure that the deepest measurement can be
detected.
2. established the base of the sulcus, a “walking” stroke should be used
where the probe is moved coronally about 2 mm and then touched
back to the base of the sulcus in repetition as you advance the probe
around the tooth.
3. Maintain the probe in the sulcus/pocket as you advance the probe.

Figure 3. Six Sites for Probing Figure 4. Walking Probe

Periodontal Probing Depth (PPD) or probing depth (PD):

Measured clinically as the distance between gingival margin and base of the
sulcus or pocket. A measurement in millimeters obtained by using a
periodontal probe.

o Sulcus depth: A physiologic (non-inflamed) space bounded by
tooth surface, the junctional epithelium, and the free marginal
gingiva (generally 1–3mm)

o Pocket depth: A pathologically deepened sulcus (often greater
than 3 mm)

22

Figure 5. A: The Sulcus, B: The PPD of 2mm

AB C

Figure 6. Recession Type (RT) according to Cairo 2011. A: RT1. B: RT2, C: RT3

Gingival recession:
The gingival recession is measured as the distance between CEJ and gingival
margin. Students are encouraged to use Cairo 2011 classification of gingival
recession as identification criterion for recording of recession. It classified the
recession type based on both buccal and interproximal attachment loss of RT1 ,
RT2 and RT3.

Recession Type 1 (RT1):
● Gingival recession with NO loss of interproximal attachment.
● Interproximal CEJ was clinically not detectable at both mesial and distal
aspects of the tooth.

Recession Type 2 (RT2):
● Gingival recession associated with loss of interproximal attachment.
The amount of interproximal attachment loss (measured from
interproximal CEJ to the depth of the interproximal pocket) was less
than or equal to the buccal attachment loss (measured from the buccal
CEJ to the depth of the buccal pocket)

23

Recession Type 3 (RT3):
● Gingival recession associated with LOSS of interproximal attachment.
The amount of interproximal attachment loss was HIGHER than buccal
attachment loss.

Clinical Attachment Level (CAL):
It is a fixed reference point in the assessment of periodontal tissue health apart
from PPD. Examination of CAL will show the progress of the periodontal tissue
health before and after treatment. Having one fixed reference point at the
cement-enamel junction (CEJ) will help clinician to determine the ‘loss’ (clinical
attachment level loss = CAL loss) or ‘gain’ (clinical attachment level gain = CAL
gain) of attachment after healing from a periodontal treatment. Calculation of
CAL is as follows:

a) When the gingival margin coincides or slightly coronal to the CEJ, the
loss of attachment equals the pocket depth.

b) When the gingival margin (GM) location is significantly coronal to the
CEJ, CAL is determined by subtracting distance of gingival margin to CEJ
from periodontal probing depth (PPD).

24

c) When the gingival margin is located apical to the CEJ, the distance
between the CEJ and the GM should be added to the probing depth or
(gingival recession + PPD)

25

In the clinic, the CAL should be examined as part of full periodontal
assessment. Student should chart the gingiva recession (R) (noted as positive
with number), overgrowth of gingival (noted as negative with number) and
PPD. The calculation of CAL loss can be determined when these parameters
available.
Calculation for CAL:

a) Any sites with evidence of recession or overgrowth should be
calculated for CAL.

b) Sites with PPD > 3mm but no evidence of recession / overgrowth
should be calculated for CAL

Mobility:

Defined as teeth that have more than physiological mobility. The methods to
measure mobility can be done by using two instruments or one instrument and
one finger (Figure 7 and Figure 8)

Figure 7. Examination of Mobility Using Two Figure 8. Examination of Mobility Using One
Instruments Instrument and One Finger

● Miller (1950) Mobility index:
Class I: first distinguishable sign of movement greater than “normal”;
Class II: movement of the crown up to 1 mm in any direction;
Class III: movement of the crown more than 1 mm in any direction and/or
vertical depression or rotation of the crown in its socket

26

Furcation Involvement:

Is the pathological resorption of bone within a furcation(s) area. The
instrument which used for measuring furcation is known as Naber’s probe. The
black marking differentiates the probe from other sickle shape instruments.

Figure 9. Naber's Probe

AB C

Figure 10. Grading of Furcation Involvement. A: Grade 1, B: Grade 2, C: Grade 3

● Hamp et al. (1975) classification of furcation invasion:
Grade I: Horizontal furcation invasion less than 3mm.
Grade II: Horizontal furcation invasion more than 3mm but not encompassing
the total width of the furcation.
Grade III: Horizontal through-and-through furcation invasion.

27

Radiographic survey:
Full mouth radiograph is indicated in patients with generalized horizontal and
vertical bone loss. This full mouth radiograph could be in the form of
orthopantomography (OPG)/ series of full mouth periapical (PA) radiograph.

Radiography will demonstrate the following features:
1. Root length and morphology
2. Clinical crown root ratio
3. Approximate amount of bone destruction
4. Relationship of maxillary sinus to the periodontal deformity
5. Condition of interproximal bony crest: horizontal and vertical
resorption.
6. Widening of periodontal ligament space on the mesial and distal
aspect of the root
7. Advanced furcation involvement
8. Periapical pathosis
9. Calculus
10. Overhanging restoration
11. Root fractures
12. Caries
13. Root resorption

Treatment planning

A treatment plan should be developed to achieve these objectives:
● Addressing and treatment of patient's main complaint.
● Sequencing the treatment according to the priority. Acute problem be
addressed first followed by other treatments required.
● Patients’ education directed at the patient's specific problems, with the
emphasis on the need to quit smoking.
● Reduction or the removal of etiologic risk factors.
● Reestablishment of the periodontal health, whether by nonsurgical or surgical
therapy.
● Maintenance of periodontal health through adequate plaque control by
patient and regular visits to the dentist.

Customized treatment should be constructed for each patient based on the phases of
periodontal therapy. There are basically 3 phases of periodontal therapy. Some books
may be divided it into 4 phases. The phases of periodontal therapy include:

1. PHASE 1: Non-surgical periodontal therapy/Initial periodontal therapy cause
related phase/ hygienic phase

2. PHASE 2: Surgical periodontal therapy/ corrective phase

28

3. PHASE 3: Supportive periodontal therapy / maintenance.
Students can include the “emergency phase” prior to phase 1 if necessary. Such
example if patient come to your clinic with an acute complaint of abscess with pain.
The patient’s acute complaint should be attended first prior to commencing other
treatment.
Re-evaluation is regarded as part of phase 1 therapy. Some books may separate the
re-evaluation phase to be the 2nd phase. Regardless of that students must understand
the aims of each phase and formulate a concise treatment plan as the blueprint for
management of periodontally compromised patients.

Sequence of treatment

Figure 11.Sequence of Periodontal Treatment

29

Phase I therapy: Non-Surgical Periodontal Therapy/Initial periodontal
Therapy/ initial Hygienic phase
The measures used in initial, cause-related periodontal therapy aim at the
elimination and the prevention of their recurrence of supra and subgingivally
located bacterial deposits from the tooth surfaces. This is accomplished by:

o Motivating the patient to understand and combat dental disease
(patient information)

o Giving the patient instruction on how to properly clean his/her teeth
(self-performed plaque control methods)

o Root surface debridement (RSD) removal of additional retention factors
for plaque such as overhang margins of restorations, ill-fitting crowns,
etc.

Phase II therapy: Surgical or corrective therapy
The goal of periodontal therapy is to develop an environment that the patient
and the dentist can maintain in a stable status with ease. If a stable state
cannot be attained or maintained with ease, surgical alteration may be useful
in achieving this goal.

The decision is made at the initial therapy re-evaluation, which should take
place several weeks (minimum of 6 to 8 weeks) after completion of the initial
treatment.

Surgery is indicated if it may make areas more accessible for plaque control
and RSD, without compromising support of potentially maintainable teeth or
creating unacceptable esthetic situations owing to root exposure. The decision
must be based upon overall evaluation of the plaque control, depth of residual
pocket, morphology of affected bone (based on radiographic assessment) and
cost.

If additional support can be gained by regenerative means, the dentist should
vigorously encourage the patient to consider the surgical alternative. If these
objectives cannot be obtained surgically, recall maintenance is the approach of
choice.

Phase III therapy: Supportive periodontal therapy (SPT)/Maintenance therapy

Most patients who have been treated for moderate to advanced periodontitis
require maintenance every 3 months. The length of time between recall
appointments is dictated by the level of the disease control accomplished by

30

patients during the interval between recall visits. The purpose of SPT include to
identify contributing factors and risk assessment; to eliminate infection and
treat progression of disease.

Root surface debridement (RSD)

Non-surgical management of periodontal disease comprises of OHI and root
surface debridement (RSD) and is considered as the basic treatment for
periodontal disease. The objective of it is to:

1. remove of plaque and calculus from the tooth surface
2. remove of subgingival plaque, calculus and necrotic cementum with the aim

being to disrupt the subgingival biofilm and create an environment more
favourable for healing.
3. remove the etiologic agents which cause inflammation to the periodontium

Root surface debridement is generally undertaken with various hand
instruments and /or ultrasonic scalers. This term is used to describe the
removal of deposits from the root surface to leave the surface clean without a
specific aim of cementum removal. It was previously thought the endotoxin
was firmly bound to cementum and the extensive cementum removal by root
planing was required. However, earlier works have shown that endotoxin is
weakly bound to the root surface and therefore, cementum removal no longer
a goal of periodontal therapy (Drisko, 2000).

As a result of RSD, plaque bacteria are reduced and there is resolution of the
inflammatory lesion in the periodontium. This leads to shrinkage of the gingival
soft tissue (as oedema resolves), increased in the resistance to probe tip
penetration by the tissues at the base of the pocket (as inflammation resolves)
and the formation of a long junctional epithelium at the base of the pocket.

The full mouth scaling or RSD should be aimed to complete within 4 weeks’
time to ensure good control of periodontal infection. The response to the
therapy is monitored 8-12 weeks or up to 3 months. Adjunctive treatment for
periodontal disease may be prescribed if deemed necessary. The removal of
deposits is technically demanding, and its effectiveness is dependent on the
site factors, operator skills and patient factors. Many studies have the
effectiveness of plaque control and instrumentation in the treatment of
periodontal disease (Badersten et al., 1984). If it does not work, however,
adjunctive treatments may be offered include antimicrobials and host
modulation agent for phase I therapy.

At the end of therapy, teeth polishing may require for staining removal. It can
be performed using a prophy-cup or bristle brush along with a polishing paste

31

or an abrasive polishing compound. Excessive polishing can, over time cause
morphological changes by abrading tooth structure away. Therefore, polishing
is indicated in case of teeth with obvious staining, post-scaling of abundance of
calculus and as part of final prophylaxis.

Fundamental of Instrumentation
Periodontal instruments are classified according to the purposes they serve as
follows:

1. Periodontal probes are used to locate, mark and measure pockets on
individual tooth surfaces.

2. Explorers are used to locate supragingival calculus deposits and caries.
3. Scaling and root planing instruments are used for removal of plaque

and calcified deposits from the crown and root of a tooth and removal
of altered cementum from the subgingival root surface.
4. Cleansing and polishing instruments such as rubber cups, brushes, and
dental tape are used to clean and polish tooth surfaces. Air-powder
abrasive systems are also available for tooth polishing.
5. The periodontal endoscope (more useful for research) is used to
visualize deep subgingivally in pockets and furcation areas enabling the
detection of deposits

General principles of instrumentation
General principles for effective instrumentation:

 Proper position of the operator and patient.
 Illumination and retraction for optimal visibility.
 Sharp instruments are fundamental prerequisites.
 A constant knowledge and awareness of tooth and root morphologic

features with the periodontal tissues condition are also essential.
 The adequate knowledge of instrument design enables the clinician to

select proper instrument efficiently for the procedure and the area in
which it will be performed.
 The basic concepts of grasp, finger rest, adaptation, angulation, lateral
pressure and stroke must be understood before clinical instrument
handling skills can be mastered.

32

CLINICAL REQUIREMENTS FOR PERIODONTOLOGY

Table 8. Clinical Requirement for Year 3

The New Clinical Requirements for Year Three (3)

1. The following requirements must be completed prior to undertaking any scaling
competencies, and students will be trained to carry out manual scaling on models:

● Introduction to the periodontal examination and charting
● Examination & Charting on each student
● Explanation on the way and content of Oral Hygiene Instructions
● Manual supragingival Scaling Demonstration
● Manual supragingival Scaling on models (ant. teeth)
● Manual supragingival Scaling on models (post. teeth)
● Manual subgingival Scaling Demonstration
● Ultrasonic scaling Demonstration
● Ultrasonic scaling on each student
2. To give successful and correct examination and charting on patients supported

by thorough oral hygiene instruction minimum THREE (3) cases (3 cases = 2
non test cases + 1 test case)
3. To perform manual scaling (supra- gingival) and prophylaxis procedures on
patients for minimum THREE (3) cases
4. To perform ultrasonic scaling (subgingival) on patients for minimum THREE (3)
cases
5. To accomplish TWO (2) successful case evaluation.
6. To sit & pass the Examination and diagnosis test. If the student’s fail this test,
the student’s is not allowed to start treating periodontitis cases in Y4.

● Patient must undergo a review of oral hygiene visit at 2 to 4 weeks before called
for re-evaluation.

33

Table 9. Clinical Requirement for Year 4 and Year 5

The New Clinical Requirements For Year Four (4)

1. Students will be trained to carry out manual root surface debridement on models
prior to undertaking any root surface debridement competencies.

2. To give successful and correct examination, diagnosis and treatment plan on
patients supported by thorough oral hygiene instruction minimum FOUR (4) cases.

3. To perform ultrasonic scaling and prophylaxis on patients for minimum FOUR (4)
cases.

4. To perform root surface debridement on patients for minimum TEN (10) sites.
5. To accomplish TWO (2) complete phase I therapy (Periodontitis/gingivitis case).
6. To represent ONE (1) successful case presentation.
7. To pass the Y3 Examination and diagnosis test
8. To sit for & pass the Competency test for scaling after completion of 10 scaling

cases before sitting the fourth professional exam – either in year 4 or 5. Those who
obtained FAIL are not allowed to present their oral case of Periodontitis in which
may affect them to undertake the FINAL PRO IV examination.

The New Clinical Requirements for Year Five (5)

1. To give successful and correct examination, diagnosis and treatment plan on
patients supported by thorough oral hygiene instruction minimum FOUR (4) cases.

2. To perform ultrasonic scaling and prophylaxis on patients for minimum FOUR (4)
cases.

3. To perform root surface debridement on patients for minimum FIFTEEN (15) sites.
4. Under the supervision of periodontics senior members students have extra marks

for participating in periodontal surgeries as assistant during surgeries.
5. To accomplish TWO (2) complete phase I therapy (at least 1 Periodontitis case).
6. To present TWO (2) successful case presentation.

 Patient must undergo a review of oral hygiene visit at 2 to 4 weeks before called
for re-evaluation.

34

* Students are required to COMPLETE all the above-mentioned requirements
by end of the academic year3, 4, & 5 as illustrated in their own logbook.
Student who fails to achieve the provided requirement, they are NOT
ELIGIBILITY to sit for the Professional Exam IV (or the Promotional Exam if it
is conducted).

35

This section to be completed by the students:
I have read this notice and fully understood the importance of completing
the requirements according to their deadline. The above-mentioned
requirements are imposed for eligibility to sit for the Professional Exam IV (or
the Promotional Exam if it is conducted).

Name: _______________________
Matric no: ____________________

Signature: ____________________
Date: ________________________
Witnessed by:

……………………………………………… Date:
Name: DR JUZAILY HUSAIN
Post: ASSISTANT PROFESSOR

....................................................... Date:
Name: DR SUHAILA MUHAMMAD ALI
Post: ASSISTANT PROFESSOR

....................................................... Date:
Name: DR MUNIRAH YAACOB
Post: ASSISTANT PROFESSOR

....................................................... Date:
Name: DR MOHD NOR HAFIZI MOHD ALI
Post: LECTURER

36

Reference books for periodontology course

CARRANZA'S CLINICAL PERIODONTOLOGY, 13th Edition, 2019.
Michael G. Newman, Henry Takei, Perry R. Klokkevold, and Fermin A.
Carranza.

CLINICAL PERIODONTOLOGY AND IMPLANT DENTISTRY, 6th Edition. 2015.
Jan Lindhe, and Niklaus P. Lang.

PERIODONTICS - MEDICINE, SURGERY AND IMPLANTS, 1st Edition, 2004.
Louis F. Rose, Brian L. Mealey, Robert J. Genco, and Walter Cohen.

PERIODONTOLOGY GUIDEBOOK FOR DENTAL UNDERGRADUATES. 1st Edition,
2016.
Erni Noor, Farha Ariffin, Mohd Faizal Hafez, Fouad Hussain Al-Bayaty,
Mahyunah Masud, Muhammad Hilmi Zainal Ariffin.

ESSENTIALS OF INSTRUMENTS AND INSTRUMENTATION IN PERIODONTAL
EXAMINATION PROCEDURES. 1st Edition, 2014.
Haslinda Ramli, Wan Mohamad Nasir Wan Othman.

37

Annex A: Staging and Grading of 2017 Periodontitis Classifications

38

39

Annex B: Rubrics for periodontics clinic

Clinical supervisors will be using the following evaluation criteria for the

assessment of student’s work.

EVALUATION CRITERIA G/A/I/R

G Good achievement as set by criteria
A Acceptable achievement with minor error
I Improvement of work required to reach acceptable level
R Redo required (work is not accepted and it should be repeated)

A) Rubrics for the assessment of calculus removal post scaling (for Year 3)

Table 10. Rubrics for the assessment of calculus removal post scaling (for Year 3)

Criteria examined Good Acceptable Improvement
for calculus post (10 -7) (6 – 5) (4 and less)
scaling No remaining
calculus can Very minimal calculus seen at Significant amount of
Calculus removal be seen deep fissured teeth that cannot calculus can be seen
● No calculus be removed even with the found at the any of
finest tip teeth surfaces except
detected visually fissures

● No supragingival No No supragingival calculus Significant
calculus detected supragingival achieved after 2 or more time Supragingival
on probe calculus being reviewed by clinic calculus detected on
examination detected supervisor some surfaces or
roughness remaining
● No subgingival No subgingival No subragingival calculus in a few areas
calculus detected calculus achieved after 2 or more time
on probe detected being reviewed by clinic Subgingival calculus
examination supervisor detected on probing
of some surfaces or
roughness remaining
subgingivally

Smooth teeth Smooth all Smooth all teeth surfaces Some teeth with
surfaces teeth surfaces achieved after few time being rough surfaces.
reviewed by clinic supervisor

Evaluation criteria: G / A / I / R

40

B) Rubrics for the assessment of root surface debridement (for Year 4)

Table 11. Rubrics for the assessment of root surface debridement (for Year 4)

Criteria Good Acceptable Improvement
examined for (10 -7) (6 – 5) (4 and less)
root surface
debridement Correct gracey’s Correct gracey’s selection Incorrect gracey’s use
Instruments selection with ability with ability to recognize and inability to
selection to recognize dull or dull or excessively worn recognize dull or
● Correct excessively worn instruments however only excessively worn
instruments & able to demonstrate instruments &
Gracey’s demonstrate proper proper instrument use & demonstrate proper
instrument use, the correct methods for instrument use, the
curretes correct methods for insertion of gracey’s after correct methods for
insertion of gracey’s being corrected by clinic insertion of gracey’s
selection supervisor
Significant amount of
Calculus removal No remaining calculus Very minimal calculus calculus can be seen
● No calculus can be seen seen at deep fissured found at the any of
teeth that cannot be teeth surfaces except
detected removed even with the fissures
visually finest tip
Significant
● No No supragingival calculus Supragingival calculus
supragingival No supragingival achieved after 2 or more detected on some
calculus calculus detected time being reviewed by surfaces or roughness
clinic supervisor remaining in a few
detected on areas
probe
examination

● No No subgingival No subragingival calculus Subgingival calculus
subgingival calculus detected achieved after 2 or more detected on probing of
calculus time being reviewed by some surfaces or
detected on clinic supervisor roughness remaining
probe subgingivally
examination

Smooth teeth Smooth all teeth and Smooth all teeth surfaces Some teeth and root
and root surfaces root surfaces but present of roughness with rough surfaces.
at root with morphologic Repeat/Failed:
No Tissue No tissue trauma variant or deformities Excessive tissue injury
trauma noticed indicative of careless
Minor tissue trauma instrumentation
noticed

Evaluation criteria: G / A / I /R

41

PERIODONTICS UNIT
KULLIYYAH OF DENTISTRY

EXAMINATION AND DIAGNOSIS TEST FOR YEAR 3 [2018/2019]

1. OBJECTIVES of Examination & Diagnosis test is to assess the students’ ability to:

a) perform satisfactory history taking of medical and dental
b) conduct a thorough clinical and radiographic examination
c) evaluate extraoral and intraoral findings
d) list the patient’s problems and established the correct diagnosis and

prognosis.
e) outline appropriate treatment plan based on the information obtained

2. ELIGIBILITY requirement to sit competency test:

2.1. The students must have experience performing TWO (2) complete
examination and diagnosis (E&D) of gingivitis cases prior to the
commencement of the test.

3. EXAMINATION procedures

3.1. Student’s has to find a NEW gingivitis cases for the test.
3.2. Student’s is responsible to arrange the test time/session with the respective

supervisor.
3.3. Supervisor should be called for evaluation after student has completed the

E&D of the gingivitis case attended.
3.4. Those who obtained PASS are allowed to see Periodontitis at Y4 at Block 1.
3.5. Those who obtained FAIL are not allowed to see Periodontitis cases at Y4 at

Block 1.
3.6. The FAILED student must find a new gingivitis case at Y3 (if has ample time)

OR a new case at early YEAR 4 BLOCK 1 for the next test.

4. RESULT of the test

4.1. Students must obtain PASS for the test before they can start clerking
Periodontitis cases at Year 4. They are not allowed to see periodontitis cases
until the student earn a PASS in the Y3 competency test.

4.2. PASS is given to student who earns SATISFACTORY grades on all skills assessed
in the test.

4.3. FAIL is given to student who earns 1 or more UNSATISFACTORY grade on all
skills assessed in the test.

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