“A CORRECT DIAGNOSIS IS THE THREE FOURTH

THE REMEDY” - MAHATHMA GANDHI

ADVANCED DIAGNOSTIC AIDS

Dr.Smitha.K
Professor and Head,
Department of Periodontology,
Government Dental college and Research Institute,
Bangalore
 QUESTION BANK

• Discuss advanced diagnostic aids .2011Nov-20 marks

• 2012May,3rd 4th paper
• 2016 May -75marks
• 2018 July 20 marks
• Discuss role of various chair side diagnostic kits in
periodontal diagnosis- June 2022 ,2020,2017nov,2016nov
 C ONTENTS

Introduction
Efficacy of diagnostic test
Limitations of conventional methods
Advances in Clinical diagnosis
Advances in Radiographic assessment
Advances in microbiologic analysis
Advances in characterizing the host response
New innovations
Conclusion
References
 INTRODUCTION

• Definition :Diagnosis is defined as; correct determination, discriminative estimation

and logical appraisal of conditions found during examination as evidenced by
distinctive marks, signs and characteristics of diseases
-Glossary of Periodontal terms (2001)
Importance :
a. It identifies and indicates the nature of etiological factors
b. Indicates the nature of pathological processes
c. It is essential for treatment planning.

A “Diagnostic” refers to tools, procedures or technologies that are used in

determination of diagnosis.
According to Armitage GC (1996) Periodontal diagnostic
procedures can potentially serve 5 separate, but related purposes:
1. Screening
2. Diagnosis of specific periodontal disease
3. Identification of sites or subjects at an increased risk of
experiencing the progression of periodontal destruction
4. Treatment planning.
5. Monitoring of therapy.
Armitage, G. C. (1996). Periodontal Diseases: Diagnosis.
Annals of Periodontology, 1(1), 37–215.
doi:10.1902/annals.1996.1.1.3
• According to Chappel for periodontal diagnosis, the ideal diagnostic test should be:(Chapple
1997)
1. Quantitative.
2. Highly sensitive method capable of analysing a single periodontal site in health as well as
disease.
3. Reproducible.
4. Highly specific.
5. Simple to perform.
6. A rapid, one or two stage procedure.
7. Non-invasive.
8. Versatile in terms of sample handling, storage and transport.
9. Amendable to chair side use.
10. Economical.
11. Dependent upon simple and robust instrumentation.
ADVANCED DIAGNOSTIC AIDS IN
PERSONALISED MEDICINE
ADVANCED PERIODONTAL DIAGNOSTIC
TECHNIQUES

Advances in Clinical diagnosis

Advances in Radiographic diagnosis

Advances in Microbiologic Analysis

Advances in Characterizing the Host Response

CONVENTIONAL CLINICAL DIAGNOSTIC TOOLS
Clinical diagnosis is made by measuring either clinical attachment
loss (CAL) or radiographically by loss of alveolar bone.
This kind of evaluation identify and quantify current clinical signs of
inflammation.
Provides historical evidence of damage with its extent and severity
LIMITATIONS OF CONVENTIONAL CLINICAL
DIAGNOSIS

 Does not provide cause of condition

 Does not provide information on patient’s Susceptibility
 Cannot reliably identify sites with ongoing
periodontal destruction or sites in remission.
 Cannot differentiate whether response to therapy is
positive or negative.
 P E R I O D O N TA L D I S E A S E I S
M U LT I FA C TO R I A L C O M P L E X D I S E A S E

Periodontal
pathogens

Host
Genetic response

Systemic Behavioural
  Microbiologic
• Consideration should  Immunologic
be given  systemic
 genetic
 behavioural factors

• In the era of Personalised medicine disease prevention, early

discovery, and intervention to minimize treatment, thus enabling
the most desirable outcomes is the focus & ADVANCED
DIAGNOSTIC AIDS have become part PRECISION
MEDICINE
• Diagnostic modalities available to clinicians today expand greatly
on the foundation of a comprehensive visual assessment, which
has been and will be the cornerstone of the diagnostic process.
Advances In Clinical Diagnosis
 ADVANCES IN CLINICAL DIAGNOSIS

•Periodontal probes
OTHERS
- Calculus detection system
- Periodontal Disease Evaluation System
- Gingival Temperature
- Tooth mobility
- Halitosis detection.
- GCF,Saliva quantification-Periotron
 PERIODONTAL PROBES

•Gold standard
• Simonton (1925) and Box (1928) were among the first to
advocate the routine use of calibrated probes
• Periodontal probes are used primarily to detect and
measure periodontal pockets and clinical attachment loss.
 PERIODONTAL PROBES

•locate calculus, measure gingival recession, width of attached

gingiva and size of intraoral lesions, identify tooth and soft-
tissue anomalies, locate and measure furcation involvements
and determine mucogingival relationships and bleeding
tendencies.
 TYPES OF PROBE:

•Pihlstrom (1992) classified probes into three generations.

• In 2000, Watts extended this classification by adding fourth

and fifth-generation probes.
 CLASSIFICATION OF PERIODONTAL PROBES
DEPENDING ON GENERATION

1.First generation probes:(conventional probes)

•Conventional manual probes that do not control probing force or
pressure and that are not suited for automatic data collection.
eg:
Williams periodontal probe Goldman Fox probe
CPITN probe Glickman probe
UNC-15 probe Merritt A and B
probe
University of Michigan’O’ probe
• Round in C.S : Merritt Probe, Gilmore Probe, William’s Probe & University Of
Michigan Probe.

• Rectangle in C.S : Goldmann Fox, Drellich probe, and Nabers probe.

• Some probes are available in combination such as Goldmann Fox on one side with
round probe at the other end.

• Merritt and Gilmore probes are the only two probes, which are not having any
calibrations.
• A modified Merritt probe is available with calibration in single increments from 1-
10 mm.
• University of Michigan probe is marked with 3, 6 and 8 mm
calibration.

• Drellich probe: Here the markings are 6, 8, & 10mm.

• Williams, Goldmann -Fox probe are marked in 1 mm increments up

to 10 mm but the markings of 4 mm and 6 mm are deleted to
facilitate the readings of measurement,
 PERIOWISE PROBE

• White, flexible, autoclavable 3,6,9,12 mm or 3,5,7,10mm probe.

• At the tip is a green band indicating a 3mm or less sulcus depth.
• Red milli meter marking are present at 5mm or 6mm and thereafter
indicating disease.
First generation probes
NIDCR criteria for overcoming
Coventional Probing
 SECOND-GENERATION (CONSTANT-PRESSURE)
PROBES:

•Pressure sensitive , not exceed 0.2 N/mm2 (Waerhaug, 1952)

•Constant force or pressure sensitive probes, was developed by Gabathuler and Hassell
in 1971.
• True Pressure Sensitive (TPS) probe , Hunter 1994 ( VIVA CARE/VIVA
DENT)
• Disposable probing head
• 20 gm & 0.5mm dia.
•These probes have a visual guide and a sliding scale where two indicator lines meet
at a specified pressure.
Examples:
• Pressure probe (Vander Volden)
• Pressure sensitive probe (PSP)
• Borodontic probe
• Yeaple probe (used to assess degree of dentinal hypersensitivity)
 In 1977, Armitage : Simple pressure-sensitive periodontal probe holder: to
standardize the insertion pressure.
 In 1978, van der Velden presented the "Pressure Probe", which allowed
probing force to be adjusted.
 - Cylinder & a Piston connected to a variable air pressure system
 The electronic pressure-sensitive probe, allowing for control of
insertion pressure, was introduced by Polson in 1980.
 Polson’s original design was modified: the probe is known as the
Yeaple probe, which is used in studies of dentinal hypersensitivity
(Kleinberg et al., 1994).
•Kalkwarf et al 1986:

• force upto 30 g Junctional epithelium

• 50 g periodontal osseous defects

PRESSURE SENSITIVE PROBE
Third-Generation (Automated) Probes:
Controlled force application, automated measurement and
computerized data capture and storage.

Eg:
 Foster-Miller probe
 Toronto probe
 Florida Probe
 Inter probe
 FOSTER MILLER PROBE

 Jeffcoat and associates introduced this probe

in 1986.
 This probe can detect the CEJ and it automatically retracts and
extends under controlled force conditions.

 As it 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.
• The MAIN ADVANTAGE is the automatic
detection of the CEJ, which is a better landmark than
gingival margin, because the position of the gingival
margin may change depending on inflammation or
recession.

• The MAIN DISADVANTAGE is that it can deem

root roughness or root surface irregularities as the CEJ
 TORONTO AUTOMATED PROBE

This probe was introduced by Birek et al. (1991) and Mc Culloch et al.
(1991) for measurements of attachment levels using the incisal or the
occlusal edges as landmarks.
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.
 The data is recorded by a microcomputer that is interfaced with the digital
length gauge.
• Reproducibility of the angulation of the probe is assured by the
incorporation of a mercury switch (Karim et al, 1990), because it forces
the examiner to hold the probe+/- 100 of a vertical position.
• Angulation within 30 degree
• Probinf forces from 0.1 N to 0.9 N
• It was modified for the measurement of probe velocity (Tessier et al
1994)
 Adv:
• Consists of incorporated electronic guidance system to improve precision in probe angulation.
• It also estimates the biophysical integrity of the dentogingival junction by measuring intrapocket probing
velocity.
Disadv:
• It is difficult to measure second and third molars, and patients have to position their heads in the same place
to reproduce readings.
 FLORIDA PROBE

The Florida probe was introduced by Gibbs et al in 1988.

It is a computerized probe which has the combined advantage of constant
probing force with pressure electronic measurement, computer storage of
data and also has a guidance system that ensures reproducible pathway.
 The system consists of a probe hand piece and sleeve, a digital read out, a
foot switch, a computer interface and a computer.
 The hemispheric probe tip has a diameter of 0.45 mm, and the sleeve
has a diameter of 0.97 mm . Constant probing pressure of 15 gm is provided
by coil springs inside the handpiece.
Adv:
 They also can record missing teeth, recession, pocket depth, bleeding, suppuration,
furcation involvement, mobility, and plaque assessment.
 Comparison to previous data can be made more quickly and accurately
 Diseased sites are shown on a chart, which can be used in patient education.
Disadv:
 Underestimating of deep probing depth and a lack of tactile sensitivity.
 Also, clinicians need to be trained to operate these probes
 INTERPROBE

 Goodson and Kondran et al developed the Interprobe in 1988.

 Flexible probe tip (Fiber optic technology), which curves with

the tooth as the probes enters the pocket area.

 The system includes a control unit, 2 memory cards ,hand piece, dot matrix
printer, foot switch, chart forms and disposable flexible probe tips.

 The Florida probe & the Florida disk probe have a resolution of 0.1 mm,
while the Interprobe has a resolution of 0.5mm.
PAROMETER
 FOURTH GENERATION PROBES: (THREE
DIMENSIONAL PROBES)

 Currently under development, these are aimed at recording sequential

probe positions along a gingival sulcus.
 An attempt to extend linear probing in a serial manner to take account of the
continuous and three dimensional pocket that is being examined.
Fifth Generation probe:
 These will add an ultrasound as another device to the 4th generation
probe.
 This will be the only noninvasive 3 dimensional probe .
The only fifth-generation probe available, the UltraSonographic (US)
probe
The US probe was devised by Hinders and Companion at the NASA
Langley Research Center.
Uses ultrasound waves to detect, image, and map the upper boundary of
the periodontal ligament and its variation over time as an indicator of
the presence of periodontal disease.
 SIXTH GENER ATION

OPTICAL COHERENCE TOMOGRAPHY?

OCT, a relatively new imaging technique, can create high-resolution cross-sectional images of biologic structures by
scanning a lightly focused light beam across the tissue surface of interest.
Conceptually, OCT imaging has been compared to ultrasound scanning .Both techniques provide structural images
using backscattered energy.

However, unlike an ultrasound, which uses sound waves, OCT uses broad-band low-coherent NIR light sources that
provide considerable
penetration into tissue with no known detrimental biologic effects.

OCT takes advantage of the low-coherence length of broadband laser light and interferometric detection to create
images with resolutions of 10 μm in the axial direction and 20 μm in the transverse plane using relatively
inexpensive light sources and optics.
COLORVUE PROBES FOR GINGIVAL
PHENOTYPE
CHU’S ESTHETIC GUAGE
NON-PERIODONTAL PROBES
CALCULUS DETECTION SYSTEM
 PERIOSCOPE

The fiberoptic endoscopy based technology for calculus detection is currently being used in
only one device, Perioscopy (Perioscopy Inc., Oakland, CA, USA).
Perioscopy is a minimally invasive miniature periodontal endoscope and is inserted into the
periodontal pocket for subgingival visualization of the root surface at magnifications of 24–
48x.
This system consists of a 10,000-pixel fiberoptic bundle with 1mm diameter surrounded by
multiple illumination fibers, a light source, an irrigation system and a display monitor with
liquid crystal.
This automated system aids in the visualization of the subgingival root surface, tooth
structure and residual calculus in real time. Also, the magnified images can be viewed on
the monitor in real time and images as well as videos can be saved in computer files.
 DetecTar

 Based on measurements of resonance vibrations of ultrasonic

treatment or autofluorescence induced by laser irritation.

 Recently, a novel calculus detection system DetecTar

(Ultradent, Salt Lake City, UT, USA) employing spectro-optical
technology has been suggested as a potential aid in detecting
subgingival calculus
 DIAGNODENT

• Based on the autoflurescent property of calculus, a newer diagnostic instrument

has been developed, the Diagnodent (KaVo, Biberach, Germany). The device
was initially launched for caries diagnosis. Later, the device was modified to
enable calculus detection.

• Diagnodent is able to measure wide range of fluorescence intensities,

transformed and shown on a digital display as relative calculus-detection
values from 0-99 . Readings corresponding to the calculus are indicated by a
beep with an increasing sound frequency as the display value increases.
• DIAGNOdent™ Classic and the DIAGNOdent™ Pen
(KaVo, Biberach, Germany), the 655 nm light is generated
by an In:Ga:As:P diode laser. This light then elicits the near
infrared fluorescence from the bacterial porphyrins
contained within the subgingival calculus deposits.
• Once the LF reading has reduced to the baseline value for
cementum or healthy dentine (e.g. an LF score of 7), no
further calculus deposits remain, and the endpoint for
instrumentation has been reached .
 FLUORESCENCE DETECTION OF DENTAL
CALCULUS USING OTHER WAVELENGTHS OF
LIGHT

• Visible red fluorescence emissions produced by calculus when excited with 405 nm violet light.
• Ultraviolet light (315–400 nm), violet light (405 nm) and visible blue light (400–420 nm) will all generate
fluorescence emissions in the visible red region. The major fluorophores are the porphyrins, particularly
protoporphyrin IX, which emits at 633 nm. This approach has been used for detecting mature deposits of
supragingival plaque and calculus.
 COMBINED CALCULUS-DETECTION
AND CALCULUS-REMOVAL SYSTEMS

• The ultrasonic calculus-detection device is based on a conventional piezo-

driven ultrasonic scaler .
• The ultrasonic based technology is currently available in Perioscan (Sirona,
Bensheim, Germany), which provides a diagnosis mode to detect calculus
deposits and a treatment mode for the conventional ultrasonic debridement at
different power levels.
• When the ultrasonic tip touches the tooth surface, it produces different light
signals both in the handpiece and in a display of the table unit. The presence
of green light indicates cementum and blue light indicates calculus. An
additional acoustic signal sounds, when the calculus is detected.
 LASER TECHNOLOGY BASED SYSTEM

• Er:YAG laser has been considered the most promising for periodontal therapy ,
mainly due to its property to ablate soft and hard tissue without major thermal
side effects. -Er:YAG lasers (Keylaser 1 or 2; Kavo, Biberach, Germany)
• Keylaser 3 (Kavo, Biberach, Germany) is the only commercially
available device, which combines calculus detection and removal in a
feedback-controlled manner.
 ADVANCED CALCULUS DETECTION
SYSTEM

• SUMMARY

• Taken together, the published data on new technology-assisted treatments are

only available from laboratory research results and have yet to show clinical
superiority in comparison with conventional systems.
DETECTION OF
HALITOSIS
 METHODS OF DETECTION

• Organoleptic measurement
• Gas chromatography
• . Sulfide monitoring
• Chemical sensors
• Indirect methds-BANA
PERIODONTAL DISEASE EVALUATION
SYSTEM

 The Diamond Probe/Perio2000 System is a dental device

designed to detect sulphide concentrations of various forms
(S, HS, H2S and CH3SH) in gingival sulci .

 The system combines a conventional Michigan “O” style

dental probe with a sulphide sensor, which measures
periodontal probing depth, bleeding on probing and sulphide
levels simultaneously.
 HALLIMETER

Halitosis or Oral malodor is most often caused by Gram –ve anaerobic bacteria
which degrades the proteins and produce volatile sulphur compounds.

These sulphur compounds can be detected by gas chromatography or the

Hallimeter (Interscan) by Rosenberg et al in 1991.
The Hallimeter is compact ,easy to use and allows chairside testing.
Its performance lacks specificity in the analysis of the different components of
mouth air in comparison to the gold standard gas chromatography with flame
photometric detection.( Tonzetich et al 1995).
 OTHER METHODS:

• Diamond Probe/ Perio 2000.

• Portable Sulfide Monitor eg :- Halimeter, TANITA
breath alert
• Gas chromatography eg :- Oral chroma
• Electronic Nose.
• Hali check.
• B/ B checker.
DETECTION OF TOOTH MOBILITY
 PERIOTEST PROBE

Periotest Probe ( Schulte et al 1992) is a hand-held

probe.
 Mobility is recorded in Periotest units (PTU) from 0 to
50.
 The instrument (BioResearch, Milwaukee, Wisconsin,
USA) taps each tooth with an impeller 16 times and
measures the time taken for the tooth to return to its
original position.
 PERIOTEST PROBE

Utilizes dynamic forces of short duration of low

millisecond range.
Evaluates “Damping” characteristics of tooth.
RANGES: 8-9: clinically firm tooth
10-19: palpable mobility
20-29: visible mobility
30-50: mobility in response to lips and tongue.
 OTHER METHODS:

• Resonance Frequency Analysis.

• Osstell® (integration diagnostics)
• A.ELECTRONIC TECHNOLOGY RESONANCE FREQUENCY ANALYSIS (OSSTELL™)
• B. MAGNETIC TECHNOLOGY RESONANCE FREQUENCY ANALYSIS (OSSTELL™ MENTOR)

• Implomates® (Bio TechOne).

• Dental mobility Checker (DMC) (Aoki and Hirakawa)
• LASER vibrometer.
 IMPLATEST

• Implatest (Q Labs Inc., Providence, R.I.) incorporates all of

the features of a conventional impulse test into a compact,
portable, self-contained probe. Data can be gathered in
seconds and is operator independent (independent of the
direction or position of test application on the implant).
 OSTELL MENTOR™.

Osstell Mentor™. Magnetic peg (smart peg™) works like a

tuning fork and Osstell ISQ
 IMPLOMATES

• Implomates was developed by Huang. This device utilizes

impact force from a transducer to excite the resonance of
implant.
 ANYCHECK

• A new damping capacity method device, Anycheck (Neobiotech,

Seoul, Korea) was introduced in 2017. This device measures the time
of contact between the impactingrod and the healing abutment. It
strikes the healing abutment six times over during three seconds and
converts the time into the implant stability test (IST) values.
 SUB GINGIVAL TEMPERATURE

Kung et al claim that these thermal probes are sensitive diagnostic

devices for measuring early inflammatory changes in the
gingival tissues.

Haffajee et al in 1992 reported that in subjects with periodontal

disease, higher sub gingival temperature were associated with
periodontal pockets that bleeding on probing, had supragingival
plaque, deeper pocket depths and greater attachment loss.
Two different rationales support this possible relationships
 First: Endotoxins of infecting bacteria especially
lipopolysaccrides from Gram –ve organisms are exogenous
pyrogens that stimulate macrophages to release
endogenous pyrogens producing fever (Bencsics et al 1995)

 Second: Bacteria respond to changes in environmental

temperature with changes in their growth rate, metabolic
activities and expression of virulence factors (Maurelli et al
1989)
 PERIOTEMP

The Periotemp is a commercially available device (Abiodent ,Danvers

,MA,USA) that resembles a periodontal probe is used to measure sub
gingival temperature to a precision of 0.1° C.
A coloured reading indicates the temperature.
The temperature probe is inserted into a pocket to determine if the site
is warmer than normal
The console indicates green for cool, red for hot and amber when
the recorded temperature is between cool and hot.
 PERIOTRON 8000

Periotron 8000 quantifies the volume of gingival fluid or saliva collected on filter paper.
It functions on the principle of capacitor (it measures the electrical capacitance of the
wet filter paper strip placed between the jaws of instrument)

Electrical field created by opposing charges on the jaws induces polarity of the molecules
which reduces the potential differences between plates and increases the capacitance.
Thus the higher the number of polar molecules between the jaws of periotron, the larger
capacitance and higher periotron scores.

Unkown fluid volumes on filter paper may determined from calibration graphs
constructed by using acurately measured quantities of fluid.
Ciantar m (1998), invastigated calibration characteristics and reliability of
periotron 8000.
Quantitative analysis was studied by recording a series of peritron reading
over a volume range of 0-1 microlt for each fluid. The results of the study
revealed that
1)Differences in calibration fluid composition are reflected in periotron
scores.
2) positioning of the filter paper strip should be standardised.
3) Calibration seems to be consistent over 1 week interval
ADVANCES IN RADIOGRAPHIC
TECHNIQUE
 Dental Radiographs are traditional method to assess destruction of alveolar
bone.

 “Conventional radiographs are very specific but lack sensitivity”

 Primary criterion for bone loss is the distance from CEJ to the alveolar
crest and distance more than 2 mm is considered as the bone loss.
 LIMITATIONS OF CONVENTIONAL
RADIOGRAPHY

 One of the main limitations of conventional radiography is that it is a

two-dimensional representation of a three-dimensional structure.

 Only interproximal alveolar bone levels can be assessed with some

level of certainty.

 Radiographs help assess the past diseases activity they do not reflect
the current disease activity.
There needs to be substantial amount of mineral loss (30-50%) before
bone resorption can be detected.

Misdirection of the central ray of the X-ray beam as well as exposure and
processing errors further limit accuracy.

Most importantly morphologic or pathologic aspects of the alveolar bone

may go undetected as a result of superimposition of teeth and other
anatomic structures
 ADVANCES IN RADIOGRAPHIC
ASSESSMENT

Digital subtraction radiography

Local computed tomography
(LCT)
 Computer-assisted densitometric
image analysis system (CADIA) Nuclear medicine bone scans
Tuned aperture computed Optical coherence tomography
tomography (TACT) (OCT)
 Computed tomography (CT)  Ultrasound imaging
 Cone-beam computed tomography
Magnetic resonance imaging
(CBCT)
(MRI)
 DIGITAL RADIOGRAPHY

Digital radiography utilizes digital detectors and they serve as a viable alternative to film-
based imaging.

Currently there are 2 technologies

1.Solid state detectors
2.Photo stimulated phosphor system
Solid state detectors are based on charge-coupled device technology.(CCD)
Or on Complimentary metal oxide semiconductor technology.(CMOS)
• Direct Method • Indirect Method

Uses a Charge Couple Device (CCD) or This method uses a phosphor luminescence
CMOS sensor linked with fiberoptic or plate, which is a flexible film like sensor
other wires to computer system placed intraorally & exposed to
conventional x-ray tube.
CCD receptor is placed intraorally as
traditional films , images appear on a A laser scanner reads the exposed plates &
computer screen which can be printed or reveals digital image data.
stored
Direct Digital Imaging
Components
•X-ray source
•an electronic sensor,
•A digital interface card,
•a computer with an analog to- digital
converter (ADC),
•a screen monitor, software, and a printer.

charge-coupled device (CCD) or complementary

Direct digital sensors- metal oxide semiconductor active pixel

sensor (CMOS-APS).

array of X-ray or light

sensitive pixels on a pure
silicon chip.
 Indirect Imaging
Photostimulable phosphor radiographic
systems

PSP is scanned with a helium-neon laser

beam. The emitted light is captured and intensified by a
photomultiplier tube and then converted into digital
data.
 Advantages:
• The elimination of chemical processing.
• Shorter exposure-to-display time.
• 1/3rd to 1/2rd of dose reduction
• Computerized images which can be stored
• Selected region in the image can be enhanced for a specific diagnostic
task.
• The software offers a variety of measurement tools
 DISADVANTAGES

Familarity with digital nature of images and understanding of

principles of image manipulation is required

Lack of infection control.

 Patient discomfort during placement.

As image can be easily manipulated, it can be misused in legal

proceedings

Grossly overexposed or underexposed images cannot be

corrected
 RADIOVISIOGRAPHY (RVG)
• Duret F et al (1988)
• Based on use of CCD
• Radio – X-ray generator connected to sensor
• Visio – storage of incoming signals during exposure and convertion
to gray levels
• Graphy – digital mass storage unit – connected to various video
printout devices

latest version
Trophy has released a wireless version of
their RVG intraoral sensor named the RVG
6500.
•Mouyen F et al (1989):
•The RVG system when compared with conventional uses considerably reduced levels
of radiation to produce an image immediately after exposure..

Adosh L in 1997 in a comparative study for marginal bone between RVG and after
surgical exploration presented that Majority showed difference of less than 0.5 mm
between two techniques

A.R. Talaiepour et al in 2005

• evaluated the accuracy of RadioVisioGraphy (RVG) in the linear measurement
of interproximal bone loss in intrabony defects.

Comparison between RVG measures and intrasurgical estimates were performed in

56 teeth with intrabony defects

 The radiographic measurements overestimated interproximal bone loss as compared

to the intrasurgical measurements:
 DIGITAL SUBTRACTION RADIOGRAPHY

First demonstrated by ZeidsesDes Plantes,1935

 Later Grondhal et al (1983) introduced this technique in periodontal diagnosis.

Jeffcoat et al (1992) used this technique in the determination of periodontal

disease
Principle: current image is superimposed on the previous. Only the areas of
change appear
 positive difference - brighter
 negative difference - darker
 Baseline project geometry and image density must be reproduced
Advantages:
• A high degree of correlation between changes in alveolar bone determined by SR
& CAL changes in periodontal patients after therapy .
• Increased detectabilityof small osseous lesions.
Disadvantages:
• Not capable to give an objective description.
• No reduction in dose
• Identical projection alignment during sequential radiograph
 COMPUTER-ASSISTED DENSITOMETRIC
IMAGE ANALYSIS SYSTEM(CADIA)

Introduced by Urs Brägger et al 1988

Video camera measures the light transmitted through a radiograph and the signals
from the camera are converted into gray-scale images.

 Offers an objective method for studying alveolar bone changes quantitatively

 Higher sensitivity and a high degree of reproducibility and accuracy.

CADIA was capable of assessing differences in remodeling activity over 4–6

weeks after periodontal surgery
 TUNED APERTURE COMPUTED
TOMOGRAPHY (TACT)

To assess tissues in three dimensions

 Based on the principle of tomosynthesis:
Series of radiographs taken from different angles
Soft ware (work bench) stacks the basic images and
reconstructed in to multi planar images
 Improves detection of defects around implants
Tyndall et al., 2002 -TACT is superior to conventional
radiography in detecting pericrestal bone gain
 COMPUTED TOMOGRAPHY (CT)

• In 1972, Godfrey Hounsfield

• The X-ray source travels helically around the patient many times, emitting a
narrow fan beam until the region of interest is covered. The beam exiting the
patient is captured in a digital sensor.
• Axial, coronal or sagittal planes.
• This is referred to as multiplanar reformatted imaging.
• While CT provides exquisite 3 D views, its ability to show very small details
remain limited, usually not more than 1-2mm .
• Currently, thin multi-thin slice spiral CT is capable of rendering uniform sub
millimeter resolution in all 3 dimensions.
 • Naito T et al. 1998, Pistorius A et al. 2001. Used Computed tomography (CT) in
studies in relation to periodontal defects.

Advantages:
1.CT completely eliminates the superimposition of images of structures outside
the area or sit of interest.
2.Second because of the inherent high contrast resolution of CT differences
between tissues that differ in physical density by less than 1% can be
distinguished,conventional radiography requires a 10% difference in physical
density to distinguish between tissues.
3.Data from a single CT imaging procedure consisting of either multiple
contiguous or one helical scan can be viewed as an image in the axial ,coronal
or saggital plane
 LIMITATIONS OF CT

1.Ekestubble et al1993,and Scaf et al 1997 have reported that the effective

dose of CT for imaging of the mandible and the maxilla is much higher
than conventional radiography.
2. CT imaging for periodontal diagnosis appears to have a unfavorable
cost-benefit ratio.

3.While developments in CT scanner technology continue to decrease the

patient dose, the acquisition of high-resolution CT images remains a
high-dose procedure.
4.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 dental X-ray units, can also be used to generate
3-D CT images at a much lower radiation dose.
Utilizes cone shaped source of ionizing radiation & 2D area detector fixed on a
rotating gantry .
Multiple sequential images are produced in one scan

Rotates 360° around the

head

Scan time typically < 1

minute
 • Image acquisition involves a Rotational scan of a x ray source
and reciprocating area detector moving synchronously around
patients head
• Many exposure are made at fixed intervals to form basic
images.

• Software programs are used to reconstruct 3D images

 INDICATIONS

Evaluation of the jaw bones

Implant placement and evaluation
 evaluation TMJ
 Bony & Soft tissue lesions
Periodontal assessment
Endodontic assessment
Alveolar ridge resorption
 Orthodontic evaluation
Airway assessment
Need for 3D reconstructions
 CT V/S CBCT

 Conventional CT scanners make use  Utilize a cone beam, which radiates from the x-ray
of a fan-beam and Provides a set of source in a cone shape, encompassing a large
consecutive slices of image volume with a single rotation.

 Conventional CT makes use of a lie-  A setting-up machine of smaller dimensions

down machine with a large gantry.
 Commonly used for hard tissue
 Greater contrast resolution & More
discrimination between different
 Ease of operation
tissue types (i.e. bone, teeth, and
soft tissue
 Dedicated to dental

 Both jaws can be imaged at the same time

 Lower radiation burden

Kelly A. and Misch et al . 2006
Compared conventional radiographs with CBCT
Results: Three-dimensional capability of CBCT offers a significant
advantage in linear measurements for periodontal defect
All defects can be detected and quantified.

Mol A and Balasundaram 2008

Evaluated The NewTom 9000 CBCT scanner
Results: Better diagnostic and quantitative information on periodontal
bone levels in three dimensions than conventional radiography can be
obtained
• B. BEZAK et al 2010
• Assessed reliability and accuracy of Cone Beam Computed Tomography (CBCT)
against CAL
• CBCT measurement protocol is reliable.
• Accuracy of CBCT measurements correlates with CAL gold standard
measurements.
• Walter C et al..2011-
Suggests that cone-beam CT may provide detailed information about furcation
involvements in patients with chronic periodontitis and so may influence treatment
planning decisions
 LOCAL COMPUTED TOMOGRAPHY
(LCT)
 Local CT is a form of CBCT, LCT distinguishes itself by using a small-field
high-resolution detector to generate a limited high-resolution 3-D volume.

 LCT generates exquisite 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.

 These characteristics of LCT make it very promising modality for imaging

the alveolar bone ,both for the assessment of bone loss and implant site
imaging.

 Limited commercial availability

• van Daatselaar 2003 based on comparison made between a full CT
geometry and a local CT geometry.

• “local CT of dental structures appears to be a promising diagnostic

instrument.”
 NUCLEAR MEDICINE BONE SCANS

• In contrast to X-ray, CT, MRI which require structural or

anatomic changes to be recorded,this technique assesses
biochemical alteration in body.

• It is a nuclear scanning test that identifies new areas of bone

growth or breakdown.

• It can be done to evaluate damage to the alveolar bones and

monitor conditions that can affect the periodontium
(including infection and trauma)
 Radioactive tracer eg. 99m technetium pertechnetate substance is
injected into a vein in the arm.

 Areas that absorb little or no amount of tracer appear as dark or "cold"

spots, which may indicate a lack of blood supply to the bone (bone
infarction) or the presence of certain types of cancer.

 Areas of rapid bone growth or repair absorb increased amounts of the

tracer and show up as bright or "hot" spots in the pictures. Hot spots
may indicate the presence of a tumor, a fracture, or an infection.
 Goldhaber and co-workers applied Nuclear Medicine to study periodontal bone
resorption in the early 1970’s

 Positive bone scans are detected in beagle dogs with advanced

experimental periodontitis kaplan 1975 .

 Jeffcoat et al 1985 –There exist a significant association with high intake

of 99mTC and bone loss in moderate to severe periodontitis

 Sensitivity of 83 % and specificty of 84 %

 Reddy et al 1991 scintillation camera images following

radiopharmaceutical administration is accurate in detecting bone loss
USES:
 determine whether a patient has active sites of bone loss and could
benefit from an experimental treatment

 to determine whether a patient who is to undergo a bone marrow

transplant has sites of active periodontal disease or occult disease
that need immediate attention.
 OPTICAL COHERENCE TOMOGRAPHY (OCT)

 Biologic imaging system in 1991 by Huang et al

 High-resolution cross-sectional images of biologic

structures by scanning a lightly focused light beam
across the tissue

 It uses broadband low-coherent Near-Infrared (NIR)

light sources

 Dental OCT images clearly depict anatomical

structures that are important in the diagnostic
evaluation of both hard and soft oral tissue
 ULTRASONOGRAPHY

Ultrasonics is a branch of acoustics concerned with sound vibrations

in frequency ranges above audible level.
 Ultrasound imaging or ultrasound scanning or sonography, is a
method of obtaining images from inside the human body through the
use of high frequency sound waves.
 Non-invasive periodontal assessment tool
 1 to 20 megahertz
 Spranger(1971) tried to determine the height of the alveolar crest
Adv:
 Ultrasound imaging can visualize periodontal and
oral tissues in vivo or ex vivo without the need for
complicated processing, fixing or staining.
 It is fast, easy and a reproducible technique.
 non-invasive nature of the imaging
 the avoidance of ionising radiation
 MAGNETIC RESONANCE IMAGING (MRI)

• Non-ionizing radiation from the radiofrequency (RF) band

• Soft tissues have a high water content, MRI provides excellent soft
tissue contrast resolution.
Indications
 Assessment of intracranial lesions
 Tumour staging
 Investigation of the tempero mandibular joint
 Diagnosis of internal derangement
 As a pre-operative assessment before disc surgery
 Implant placement.

Adv:
 It offers the best resolution of tissues of low inherent contrast.
 No ionizing radiation is involved
 Since the region of the body imaged is controlled electronically,
direct multiplanar imaging is possible without reorienting the
patient.
Disadv:
 Expensive
 Requires considerable scan time for high resolution images
 May be claustrophobic for the patient
 The potential of causing movement of ferromagnetic metals in the vicinity
of the imaging magnet
 Metals used in dentistry for restorations or orthodontics will not move but
may distort the image in their vicinity.

Schara et al 2009
In an invitro study evaluated the used the use of MRI to characterize
inflammation and healing process in periodontal tissues

It was concluded that MRI can characterize the type and healing process of
inflammation
 PHOTODENSITOMETRIC ANALYSIS
TECHNIQUE
 It is based on the absorption of a beam of light by the radiographic film
which shows the image of an aluminum scale.

 It also has the ability to transform density reading into 1mm of aluminum
equivalent.

 This is accomplished by a microdenstiometer linked to a microcomputer.

 It has the advantages of allowing detection and recognition of variations that

cannot be detected by visual inspection, it also helps quantify bone changes
and study the furcation areas (Edwin et al 2000).
IMPLANT IMAGING
 2012

•In 2000, the American Academy of Oral and Maxillofacial Radiology

•(AAOMR) recommended “some form of cross-sectional imaging be used
for implant cases “
•conventional cross-sectional tomography be the method
 PRINCIPLES OF IMAGING FOR
DENTAL IMPLANT ASSESSMENT

 Images should have appropriate diagnostic quality and not contain

artifacts that compromise anatomic-structure assessments
 Images should extend beyond the immediate area of interest to
include areas that could be affected by implant placements

 Practitioners should have appropriate training in operating

radiographic equipment and competence in interpreting images
from the modality used
• INITIAL EXAMINATION:

The purpose is to assess the overall status of the

remaining dentition,to identify and characterize the
location and nature of the edentulous regions and to
detect regional anatomical abnormalities and pathologies.
• Panoramic radiography should
RECOMMENDATION 1
be used as an imaging modality

• use IOPAs to supplement

RECOMMENDATION 2
panoramic radiography
• Do not use cross sectional imaging
RECOMMENDATION 3 as an initial diagnostic aid
 Preoperative site specific imaging:
 Establish characteristics of residual alveolar bone
 Determining orientation of RAR
 Identifying local conditions restricting implant placement
 Match imaging findings to the prosthetic plan

• The radiographic examination of any potential implant site should

RECOMMENDATION 4 include cross sectional imaging orthogonal to the site of implant

• CBCT shold be considered as the imaging modality of choice for

RECOMMENDATION 5 preoperative cross-sectional imaging of potential implant sites.

• CBCT should be considered when clinical conditions indicate a need

RECOMMENDATION 6 for bone augmentation or site development before placement of
dental implants.

• CBCT imaging should be considered if bone reconstruction and

RECOMMENDATION 7 augmentation procedures have been performed to treat bone volume
deficiencies before implant placement
 • Post operative imaging

Patient has
mobility or
In the absence altered Implant
of clinical signs sensation use retrieval
use IOPAS or cross sectional
OPGs imaging CBCT

/CBCT
RADIOGRAPHS IN PERIODONTAL DISEASE
DIAGNOSIS AND MANAGEMENT

Features of periodontal diagnostic interest are apparent on

radiographs

Relationship exists b/w clinical attachment and

radiographic bone height

Radiographs can be used in all stages of periodontal care

 ADVANCES IN
MICROBIOLOGIC ANALYSIS
 Subgingival microenvironment has 300+ species .

 Only few organisms are thought to be involved with periodontal

disease.

 Strong evidence for Aggregatibacter actinomycetemcomitans (Aa),

Porphyromonas gingivalis (Pg), and Tannerella forsythia (Tf).

 Other organisms that are thought to have etiologic role are

Camphylobacter rectus, Eubacterium nodatum, Fusobacterium
nucleatum, Peptostreptococcus micros, Prevetolla intermedia and
Prevetolla nigrescens, Trepenoma denticola.
• Microbiological tests have been developed to detect selected
periodontopathic organisms.

• These test kits help the clinician in determining whether or not an

antimicrobial agent and which one may provide additional therapeutic
benefit for the patient.
Uses of microbiologic analysis

1. Support diagnosis of various periodontal disease

2. Can tell about initiation & progression

3. To determine which periodontal sites are at high risk for active

destruction

4. Can also be used to monitor periodontal therapy.

• MICROBIOLOGICAL DIAGNOSTIC METHODS
• Bacterial culturing
• Methods based on Immune diagnosis
DFA
IFA
Flow cytometry
ELISA
LATEX AGGLUTINATION
• Enzymatic methods of bacterial identification
BANA
• Molecular biology technique
Nucleic acid probes
Checkerboard DNA-DNA hybridisation technology
 BACTERIAL CULTURING

• Historically, culture methods have been widely used in studies aimed at

characterising the composition of the sub- gingival microflora.

• are still considered as gold standard in periodontics for deciding the

microbial diagnosis.
• Since majority of periodontal pathogens are anaerobic in nature, anaerobic
culture techniques have been the major tool of oral microbiologists to study
these microbes.
• Biobags, Pre-reduced Anaerobically Sterilized (PRAS) Media,
Anaerobic Chambers And Anaerobic Jars that are used with a
combination of basal and selective media for the isolation of periodontal
pathogens.
• It was realized more than 100 years ago that all the bacteria from the oral
cavity visualized under the microscope cannot be grown in culture media
in the laboratory, leading to what is called as “The Great Plate Count”
Anomaly.

• Various theories formulated to explain this phenomenon are as follows:

• 1. Lack of essential nutrients or growth factors in the artificial culture
medium,
• 2. Overfeeding conditions where in too much of nutrients are incorporated
into the medium.
• 3. Toxicity of the culture medium itself, leading to inhibition of bacterial
growth,
• 4.Production of substances (metabolic end products, toxins) inhibitory to
certain bacteria by other species present in the immediate vicinity,

• 5. Metabolic dependence on other species present in the community for

growth,

• 6. Disruption of inter-bacterial communication systems induced by

bacterial disruption during sample processing and

• 7. Bacteria could be present in a viable but dormant state.

Advantages of bacterial culturing:

• Possibility to obtain relative and absolute counts of the cultured species.

• Moreover, it is the only method able to characterise properly new species and to
assess the antibiotic susceptibility of the grown bacteria
(Socransky et al. 1987, Greenstein 1988, Marchal et al. 1991, Lamster et al.
1993).
Disadvantages of bacterial culturing:

• Culture methods can only grow viable bacteria; therefore, strict sampling and
transport conditions are essential.

• Moreover, some of the putative pathogens, such as Treponema sp. and Tf, are
very fastidious and difficult to culture. The sensitivity of bacterial culturing can
be rather low, especially for non-selective media, with detection limits averaging
103-104 bacterial cells, and therefore, low numbers of a specific pathogen in a
subgingival sample will be undetected.

• However, the most important drawback is that culture requires specific

laboratory equipment and experienced personnel, besides being relatively time
 DIRECT MICROSCOPY

• Microscopic studies of periodontal microbiota were the first to demonstrate the

existence of distinctive microbial population in association with various states of
periodontal disease and health.

• Dark-field or phase- contrast microscopy is the oldest method of microscopy and it

is used to identify spirochetes and other motile organisms in plaque sample.

• However, most of the putative periodontal pathogens like Aa, Pg, Tf; which are
nonmotile and therefore this method cannot identify these species.
AIM: the purpose of this study was to determine if a periodontal abscess could be differentiated from
an endodontic abscess by the types and proportion of microorganisms found in the abscess exudate in
darkfield microscopic examination.
CONCLUSION: In periodontal abscesses the occurrence of spirochetes ranged from 30 to 60%,
whereas in endodontic abscesses the range was 0 to 10%. Thus, the percentage of spirochetes as seen
by darkfield microscopy may be of value in the differential diagnosis of periodontal and endodontic
abscesses.
 MI CROBI AL A NA LY S I S I N P ERI ODONTICS AIMS TO:

• • discriminate between different microbial types of periodontal infections;

• • select subjects likely to benefit from adjunct systemic antimicrobial

therapy;

• • assist in selecting the most appropriate antibiotic treatment in

accordance with the composition of the subgingival microflora;

• • contribute to minimizing overuse of potent antimicrobial agents and the

emergence of antimicrobial resistance;
van Winkelhoff AJ, Winkel EG. Microbiological diagnostics in periodontics:
biological significance and clinical validity. Periodontol 2000. 2005;39:40-52.
 MI CROBI AL A NA LY S I S I N P ERI ODONTICS AIMS TO:

• • screen for horizontal and vertical transmission of periodontal

pathogens among family members;

• • help to determine the endpoint of active periodontal treatment and to

establish the recall interval for periodontal maintenance care;

• • help select patients in need for periodontal treatment before inserting

implants in partially edentulous subjects. This may especially be
indicated in subjects with a history of periodontitis
van Winkelhoff AJ, Winkel EG. Microbiological diagnostics in periodontics:
biological significance and clinical validity. Periodontol 2000. 2005;39:40-52.
 IMMUNODIAGNOSTIC METHODS

 Immunological assays use fluorescent conjugated antibodies that recognize

specific bacterial antigens and the identification of these specific antigen-
antibody reactions allows the detection of target microorganisms.

 This reaction can be visualized using a variety of techniques and

reactions:
1. Direct (DFA) and indirect (IFA) immunofluorescent assays
2. Flow cytometry
3. Enzyme-linked immunosorbent assay (ELISA)
4. Latex agglutination
5. Immunoblotting (western blotting)
 IMMUNOFLUORESCENT ASSAYS:
• Mainly used to detect specific target antigens.

• Here antigenic determinants in patient specimens are immobilized and fixed onto
glass slides with formalin, methanol, ethanol or acetone. Monoclonal or polyclonal
antibodies conjugated (attached) to fluorescent dyes are then applied to the specimen.

• After appropriate incubation and washing, the slide is viewed using a microscope
equipped with a high-intensity light source (usually halogen) and filters to excite the
fluorescent tag.

• Most kits used in clinical microbiology laboratories use fluorescein isothiocyanate

(FITC) as the dye; FITC fluoresces a bright apple-green.
• Fluorescent antibody tests are performed using either a direct
(DFA) or indirect (IFA) technique .

•In the DFA, fluorescein isothiocyanate (FITC) is conjugated

directly to the specific antibody.

• In the IFA, the antigen-specific antibody is unlabeled and a

secondary antibody (usually raised against the animal species from
which the antigen- specific antibody was harvested) is conjugated
to the FITC.
The IFA is a two-step or sandwich procedure. IFA is more
sensitive than DFA, although DFA is faster since there is only one
incubation step.

The major advantage of Immunofluorescence microscopy assays

is that they allow visual assessment of the adequacy of a specimen.
Fluorescence fades rapidly over time, which makes the archiving of
slides difficult.

Therefore, antibodies have been conjugated to other markers besides

fluorescent dyes. These newer colorimetric labels use enzymes, such
as horseradish peroxidase, alkaline phosphatase, and avidin-
biotin to detect the presence of antigen by converting a colorless
substrate to a colored end product.
• IFA has been used mainly to detect Aa, Pg and Tf.

• Zambon et al. showed that this technique was comparable with bacterial
culture in its ability to identify Aa and Pg in subgingival plaque samples.
 In fact, IFA demonstrated a higher sensitivity when compared with culture,
probably because of a lower detection limit. Comparative studies indicated
that the sensitivity of these assays ranged from 82% to 100% for detection of
Aa and from 91% to 100% for detection of Pg, with specificity values of 88%
to 92% and 87% to 89%, respectively (Zambon et al1985, 1986).
 IMMUNO PRECEIPITATION

• The immuno precipitation technique detects soluble

antigens that react with antibodies called precipitins.

• A precipitation ring test.

• Antibodies and antigens diffuse towards each other in a

test tube.
• A precipitation ring is formed at the zone of equivalence
 IMMUNOELECTROPHORESIS
• Immunoelectrophoresis is a technique in which antigens are first separated based on
their electric charge, then visualized by the precipitation reaction.
 IMMUNOBLOTTING

(Western blot): The immunologic technique involves polyacrylamide gel

electrophoresis of a protein specimen followed by a transfer of the separated
proteins to nitrocellulose sheets.
Protein bands are then visualized by treating the nitrocellulose sheets with
solutions of enzyme tagged antibodies.
This procedure demonstrates the presence of common and specific proteins
among different strains of micro organisms.
 FLOW CYTOMETRY

Rapid identification
 Principle is labelling bacterial cells with both species-specific antibody
and a second fluorescein-conjugated antibody
This suspension is introduced into flowcytometer, which separates
bacterial cells into an almost single cell suspension
 Limitation is sophistication and cost involved with this procedure
 FLOW CYTOMETRY

The basic components are:- Fluidics, Optics and

Electronics.
The fluidic system transports particles in a stream
to the laser beam.
The optical system illuminates the particles for
detection of resultant light signals by optical fibers
and
The electronic system converts the detected light
signals to electronic signals that can be processed
by the computer.
 ENZYME LINKED IMMUNOSORBANT ASSAY

• Similar in principle to other radioimmunoassays, but instead of the

radioisotope, an enzymatically derived color reaction is substituted as the
label.
• The intensity of the color depends on the concentration of the antigen and it
is usually read photometrically for optimal quantification.
• ELISA has been used primarily to detect serum antibodies to periodontal
pathogens.
• Also important diagnostic tools for Hepatitis B s Ag
and HIV p24 protein all indicators of early, active, acute infection.
• Types: Membrane immunoassay. (nitro cellulose, nylon).
Solid phase immunoassay.

• A membrane immunoassay has been adapted for chair-side clinical

diagnostic use and has been marketed (Evalusite).
• It involves linkage between the antigen and a membrane bound antibody to
form an immuno complex that is later revealed through a calorimetric
reaction.
• Evalusite has been designed to detect Aa, Pg and Pi (Boyer et al. 1996,
Chaves et al. 2000).
• Snyder et al. (1996) found a detection limit of 10 5 for Aa and 106 for pg.
MEMBRANE IMMUNOASSAY
DIRECT SOLID PHASE IMMUNO ASSAY
 PRINCIPLE OF INDIRECT
SOLID PHASE IMMUNO ASSAY
(can detect minute amount of Ag
<1ng/ml).
 PRINCIPLE OF
SANDWICH SOLID
PHASE IMMUNO ASSAY
COMPETITIVE ELISA
 LATEX AGGLUTINATION TEST

Latex beads coated with species specific AB when beads come in contact with specific
species in sample they bind and agglutination occurs clumping of beads is visible test
positive.
 There are 2 types of latex agglutination test:
1. The indirect assay
2. The inhibition assay

• The indirect assay is the most common test for bacteria. The antibody is
bound to latex. When a suspension of plaque sample is mixed with the
sensitized latex and gently agitated for 3-5 minutes agglutination or clumping is
indicative for positive result of the bacteria being tested.

• The latex inhibition assay is based on the principal of inhibiting the expected
agglutination reaction between known antigen and known antibody as a result of
competition. (Nisengaurd et al 1992).
• THIS STUDY DESCRIBE THE development, characterization, and initial
application of latex agglutination assays for periodontal pathogens.
Latex reagents were prepared by sensitization of latex microspheres
with rabbit IgG antibodies to either Actinobacillus
actinomycetemcomitans, Porphyromonas gingivalis, or Prevotella
intermedia.
• Advantages:
Quantitative estimate of target species
 Not requiring stringent sampling and transport
methodology
 Higher sensitivity and specificity than bacterial culturing
for A.a, P.g and T.f.
Disadvantages:
Limited to the number of antibodies tested
Not amenable for antibiotic susceptibility
Lack the evidence of well controlled clinical studies
Enzymatic Methods Of Bacterial Identification ( BANA).

• Tf, Pg, the small spirochete Td and Capnocytophaga species share a common
enzymatic profile, since they all have a Trypsin-like enzyme in common.

• The activity of this enzyme can be measured with the hydrolysis of the colourless
substrate N-benzoyl-DL-arginine-2-naphthylamide (BANA).

• A diagnostic kit has been developed using this reaction for the identification of this
bacterial profile in plaque samples (Perioscan).
• Principle of BANA test
• Peptidases of these three bacterial species (T. denticola, P. gingivalis, and B.
forsythus) can hydrolyze the peptide analog N-benzoyl-DLarginine-2 naphthylamide
(BANA).

• One of the hydrolytic products of this reaction is beta naphthylamide, which reacts
with a reagent, which is imbedded in the upper strip of the test, producing a
permanent blue color.
• The BANA test is a plastic strip to which two separate reagent matrices are attached.
• The lower white reagent matrix is impregnated with N benzoyl- DL-arginine-B-
napthylamide (BANA). Subgingival plaque samples are applied to this lower matrix.

• The upper buff reagent matrix contains a chromogenic diazo reagent, which reacts
with one of the hydrolytic products of the enzyme reaction, forming a blue color. The
blue color appears in the upper buff matrix and is permanent. The intensity of the
color determines whether it is a positive or weak reaction.
• Loeshe et at in 1986 proposed the use of BANA reaction in subgingival plaque samples.

• Using probing depths as a measure of periodontal morbidity, they showed that shallow
pockets (2-3mm)exhibited only 10% positive BANA reactions, whereas deep pockets
(7mm) exhibited 80-90% positive BANA reactions.

Loesche WJ. The identification of bacteria associated with periodontal disease and dental caries by enzymatic methods.
Oral Microbiol Immunol. 1986 Nov;1(1):65-72.

• Loesche et al. 1992 tested the diagnostic utility of the BANA test compared with
culture, IFA, ELISA and DNA probes, rendering similar results with regard to
sensitivity and accuracy (above 90% to detect combination of these organisms).

Loesche WJ, Lopatin DE, Giordano J, Alcoforado G, Hujoel P. Comparison of the benzoyl-DL-arginine-naphthylamide
(BANA) test, DNA probes, and immunological reagents for ability to detect anaerobic periodontal infections due to
Porphyromonas gingivalis, Treponema denticola, and Bacteroides forsythus. J Clin Microbiol. 1992 Feb;30(2):427-33.
 DISADVANTAGES OF BANA

• May be positive in clinically healthy site

• Cannot detect sites undergoing periodontal destruction
• Limited organisms detected
• So that, negative results does not rule out the presence of other
important periodontal pathogens.
 MOLECULAR BIOLOGY TECHNIQUES

 The principles of molecular biology technique reside in the analysis

of DNA, RNA and the structure and function of proteins.
 Diagnostic assays require specific DNA fragment that recognize
complementary-specific DNA sequences from target microorganisms.
 This technology requires bacterial DNA extracted from the plaque
sample and amplification of the specific DNA sequence of the target
pathogen.
 DNA PROBES

• A DNA probe is a fragment of nucleic acid that can seek out and bind itself to other
complementary sequences of DNA, thus forming the double helix structure found by
nature.
• The DNA library included probes for A.a., P.gingivalis, C.rectus, E.corrodens,
F.nucleatum,and T.denticola.
• These probes can detect bacteria as few as 102 to 104 cells.
• The plaque sample is first denatured to obtain single strain bacterial DNA &
this is isolated on nitrocellulose membrane. The specific labeled DNA probe
is incubated on the membrane to allow hybridization of the 2 single strains to
take place, which can be visualized via label in the probe.
 DNA PROBES

• Advantages • Disadvantages
Very specific and determine Very expensive
phenotypic markers The minimal detection limits for
Has great specificity and sensitivity particular species are 103–105
Not affected by transport conditions cells
Do not require anaerobic conditions to The chairside diagnosis is not
be maintained possible
 Can be done in dead bacteria and The cross reactivity by
they do not depend on bacterial oligonucleotide probes can occur
viability. Antibiotic sensitivity is not
possible.
 OMNIGENE (DMDX)

• It is nucleic acid technology genomic probe.

• Pi, Pg can be detected with the aid of purified DNA

fragments, but the same way Aa could not be detected.

• van Steenbergen et al found the DMDx detection method to possess 96% sensitivity and
86% specificity for spiked laboratory specimens of Aa and 60% sensitivity and 82%
specificity for laboratory specimens of Pg.

• For Pg, the sensitivity was 71% and the specificity 53%.

• Disadvantage : In clinical specimens, the detection of Aa revealed sensitivity as low as

21% and a specificity of 83%.
 INSTITUTE FOR APPLIED IMMUNOLOGY ( IAI) PADO TEST 4.5

• With the Pado RNA probe test kit, four periodontal pathogens can be detected: Aa, Pg,
Tannerella Forsythia, and T. denticola.
• This test basically uses oligonucleotide probes complementary to conserved fragments of
the 16S rRNA gene that encodes the rRNA, which forms a subunit of the bacterial
ribosome.
• The detection threshold of this test is 103 for Aa and 104 for Pg, T. forsythia and T.
denticola.
• The detection frequencies found with this test indicated a low sensitivity of the Pado Test
4.5 method when compared to the checkerboard method.
Disadvantage:
• The Pado Test 4.5 seems to underestimate the number of positive sites/individuals
suggested by a high number of false negatives.
• The aim was to compare the detection frequency of periodontopathogens by
using the Pado Test 4.5 and checkerboard DNA-DNA hybridization
technique in chronic periodontitis patients.
• Thirty patients with chronic periodontitis were tested cross-sectionally with
DNA/RNA oligogenomic probe method (IAI Pado Test 4.5) and DNA/DNA
whole genomic probe (checkerboard) method.
• The detection frequencies observed for this test show a poor sensitivity and
the test appears to undercount the number of positive sites/individuals exposed
as a result of a large number of false negatives
 MY PERIOPATH

• My PerioPath is DNA test used to identify the type and

concentration of the particular bacteria that cause periodontal
diseases using saliva sample. This test requires the shipping
of saliva samples to a laboratory for results.
• Detects (from bacterial DNA) the specific bacteria known to
cause periodontal inflammation and destruction
 MY PERIOPATH
• Eleven species fall within this group
• Sub‑divides these bacteria into “risk” groups based on known risk/virulence properties:
high, moderate, low
• It detects active periodontal disease by detecting the bacterial load by estimating high
risk pathogens like A.actinomycetemcomitans, P.gingivalis, T.forsythia, T.denticola,
moderate risk pathogens like E.nodatum), Fusobacterium.nucleatum (F.nucleatum),
P.intermedia, Campylobacter rectus (C.rectus), Parvimonas micros (P.micros) and low
risk pathogens like Eikenella corrodens (E.corrodens), Capnocytophaga sputigena
(C.sputigena)’
• Determines concentration/bacterial load (e.g., inflammatory burden)
• Helps to determine therapy options based on bacterial risk assessment.
 CHECKERBOARD DNA-DNA
HYBRIDIZATION TECHNOLOGY

• Socransky et al. (1994) developed this technique for the detection and levels of
40 bacterial species commonly found in the oral cavity.

• The assay uses whole genomic, digoxigenin-labelled DNA probes and

facilitates rapid processing of large numbers of plaque samples with respect to
a multiple hybridisation for up to 40 oral species in one single test.

• The DNA probes used in this technology are commonly be adjusted to permit
detection of 104 cells of each species, but can adjusted to detect 103 cells.
• The method requires sophisticated laboratory equipment and expertise, and it is highly
specific.

• These factors have not led to generalisation of this assay for diagnostic purposes.

• It is particularly applicable, however, for epidemiological research and ecological studies,

since it does not require viable bacteria and allows for the assessment of a large number of
plague samples and multitude of species

• Papapanou et al. (1997) made a comparison of this method with culture for the identification
of subgingival bacteria. The checkerboard technology resulted in higher prevalence
figures for half of the species tested (Pg, Pi, Fn and Tf) and statistically significant higher
bacterial counts for the majority of the species. Both techniques rendered a reasonable degree
of agreement.
 3. POLYMERASE CHAIN REACTION (PCR)

• Repeated cycles of oligonucleotide (primer)–

directed DNA synthesis of “target sequences”
are carried out in vitro.
• The PCR method is considered the fastest and
most sensitive method available for detecting
the presence of bacterial DNA sequences
• A modification of the original PCR technology,
"real-time" PCR, permits not only detection
of specific microorganisms in plaque, but also
its quantification.
Advantages
• High detection limit. As less as 5- 10 cells can be amplified and
detected.
• Less cross reactivity under optimal conditions
• Many species can be detected simultaneously

Disadvantage
• Small quantity needed for reaction may not contain the necessary target
DNA
• Plaque may contain enzymes which may inhibit these reactions.
 EVALUSITE

• It is a novel membrane immunoassay

commercially available in Europe and
Canada for the Chairside detection of 3
periodontal pathogens.
• It involves linkage between the antigen and
a membrane bound antibody to form an
immunocomplex that is revealed through a
calorimetric reaction.
• Merits:
It employs a normal membrane base enzyme immunoessay for the
detection of three putative periodontopathogens. (Aa, Pg, Pi).
Demerits :
It is multistage test.
It has a subjective calorimetric end point.
There is no permanent record of the result.
Gives the assumption that the three organisms are causing the disease
 PERIO 2000
• Degradation of serum proteins (cysteine and methionine) leads to Volatile
Sulphide Compounds (VSCs) production by microorganisms like P.
gingivalis, P. intermedia and T. forsythia.
• Evaluations of VSCs are indicative of subgingival microbial load as it plays
role in degrading periodontal structures aggravating periodontitis.
• Perio 2000 system displays the sulphide level digitally at each site.
• Sterile wash solution is used to hydrate the tip then at peak or hold
operational mode it is inserted subgingivally.
• After obtaining the reading, the tip is washed and reinserted in other
subgingival site.
Shankar S, Nayak R, Mohanty R, Mohanty G, Panda S, Das A. Chairside Diagnostic Aids in Periodontics: A
Review. Indian Journal of Forensic Medicine & Toxicology. 2020 Oct 1;14(4).
 MERIDOL PERIODIAGNOSTICS

• It is a real – time PCR for the quantitative determination of the six most important marker
organisms of periodontitis and peri- implantitis and the total bacterial load. (Jervoe-Storm et
al. 2005)
• The marker organisms are Agregatibacter actinomycetemcomitans, Porphyromonas
gingivalis, Tanerella forsythus, Treponema denticola, Fusobacterium nucleatum and
Prevotella intermedia.
• It combines high specificity with high sensitivity and a precise quantification.
• The detection limit, at 100 bacterial cells per type of pathogen, is far below the limits of
methods available.
• Making it highly sensitive.
ADVANCES IN CHARACTERIZING THE
HOST RESPONSE
Assessment of host response refers to the study of
mediators by immunologic or biochemical methods,
that are recognized as a part of individual’s response to the
periodontal infection.

Biomarker or Biological marker is a substance that is

objectively measured and evaluated as an indicator of
normal biologic process, pathologic process or
pharmacological response to the therapeutic intervention.

(Biomarker Definition working group, 2001)

CURTIS( 1991) clearly differentiated disease
markers as

1. Indicators of current disease

2. Predictors of future disease progression

3. Predictors of future disease at currently

healthy sites
Mediators

1. specific Mediator - antibody to a putative pathogen

2. less specific reaction - the local release of the inflammatory mediators,

host derived enzymes and tissue breakdown products

Diagnostic tests have been developed that add measures of the

inflammatory process to conventional clinical measures.
• Sources of the sample are: GCF, gingival crevicular cells, Saliva, Blood serum, blood
cells and rarely urine.
• Most efforts to date have been based on use of components of GCF and to a lesser extent,
saliva and blood
 CANDIDATES OF BIOMARKERS IN
PERIODONTAL DISEASES

• Bacteria and their products.

• Inflammatory and immune products.
• Connective tissue breakdown products.
• Enzyme released from dead cells.
• Mediators of bone resorption.
 1. INFLAMMATORY MEDIATORS AND
PRODUCTS

 Cytokines present in GCF and investigated as potential diagnostic markers are:

TNF-alpha
IL-1 α
IL-1β
IL-6
IL-8
PGE2 (product of COX pathway)
 Cross sectional studies have shown good correlation with disease status and severity but not
disease progression
 In cases of untreated periodontitis concentration of PGE2 was found increased
.
 HOST DERIVED ENZYMES
• Breakdown of collagen occurs by two different pathways:
• Intracellular
1. Aspartate amino transferases
2. Alkaline phosphatase
3. β- Glucuronidase
4. Elastase
• Extracellular
Matrix metalloproteinase's family (MMPs)
Tissue Breakdown Products
• Analysis of GCF obtained from sites with active periodontitis clearly shows
elevated levels of Hydroxyproline from collagen breakdown and GAGs
from matrix degradation.
• Osteocalcin and type-1 collagen peptides- progression of alveolar bone loss.
Biochemical test kits
 Prognostik- to detect elevated levels of MMPs

 Periocheck- to measure neutral protease activity

 PerioGard- to detect AST

 Pocket Watch- simple method for AST

 Biolise-to detect elastase activity

 TOPAS-to detect bacterial toxins and proteins (markers of

infection)
 PROGNOSTIK

• Prognostik (Dentsply) detects the presence of serine protease and

elastase in GCF samples.
• The elevated levels may, hence, indicate the presence of underlying
disease.
• The GCF is collected onto the filter paper strip impregnated with a
known amount of buffered elastase substrate labeled with a
fluorescent indicator.
• Elastase on the test strip cleaves the substrate during the reaction
time of 4–6 min and releases the indicator, visible under fluorescent
light.
 PERIOCHECK

 This Periocheck system detects the presence of neutral serine protease.

 It is the most rapid chairside diagnostic test for neutral proteases such as
collagenases, elastases, and proteinases in GCF.

Procedure:
 The GCF sample strip is placed on a gel containing insoluble dye ‑labeled
collagen fibrils (remazo brilliant blue ‑collagen substrate powder) and incubated.
 In the presence of neutral proteases (which diffuse from the strip into the gel),
the insoluble collagen‑dye complex is digested to release soluble dye ‑labeled
fragments, which diffuse back into the strip, turning it blue.
 PERIOGARD

• The Periogard system (Xyntronys Inc,San Diego CA,USA ) was designed as a

chair side test kit for (AST) Aspartate aminotransferase levels in active and
inactive periodontal lesions (Eley et al 1998)

• Aspartate aminotransferase (AST), is a soluble intracellular cytoplasmic enzyme,

present in the GCF, which is released as a result of cell death. Periodontal tissue
destruction causes cell death. Hence AST becomes a potential marker for the
presence of periodontal disease.
• The test involves the collection of GCF with the filter paper strip which is then
placed in tromethamine hydrochloride buffer. A substrate reaction mixture
containing 1‑aspartic and α‑ketoglutaric acid is added to the sample and
allowed to react for ten minutes.
• Consists of a tray with two test wells for each tooth, and appropriate reagent for
conducting the test.

• The test involves the collection of GCF with the filter paper strip which is then
placed in tromethamine hydrochloride buffer. A substrate reaction mixture
containing 1‑aspartic and α‑ketoglutaric acid is added to the sample and
allowed to react for ten minutes.
• The addition of a dye such as fast red results in a color product, the intensity
of which is proportional to the AST activity in the GCF sample.
• The test is designed to be positive at >800 µIU of AST activity and negative
at values <800 µIU.

• It cannot discriminate between sites with severe inflammation but with no

attachment loss from sites with attachment loss.
 POCKET WATCH

• An in-vitro diagnostic test kit PocketWatchTM (Steri-Oss Inc,

Yorba Linda, CA, USA) (Periodontal tissue monitor system)
has been developed also to analyze the Aspartate
aminotransferase (AST) levels in GCF, at chair side.

• It is an indicator of cell death, thus implying the severity of

periodontal tissue destruction.

 POCKET WATCH

•
• The Pocket Watch detects elevated levels (>1200IU) of AST in GCF and is
used as an objective, biochemical test for diagnosing and monitoring the
disease activity, to determine when to treat, and also to evaluate the treatment
effectiveness.
 POCKET WATCH

• Principle: The conversion of cysteine sulfuric acid, belonging to an amino

group, to alpha keto-glutaric acid to yield beta sulfinyl pyruvate, is
accelerated by AST in the presence of pyridoxal phosphate.
• As a result of the instant degradation of β-sulfinyl pyruvate, inorganic sulfite
is produced. It reacts with malachite green because of which dye looses its
colour, thereby producing pink-colored rhodamine B dye.
• The amount of conversion of malachite green determines the levels of AST.
 BIOLISE

• Recently a software has been made Biolise (SLT-Lab

instruments, Craitsheim, Germany) which is used to detect
the elastase activity in gingival crevicular fluid.
• It was developed by Hermann et al (2001).
 TOPAS
The new TOPASTM (Toxicity Prescreening Assay) test kit
has been introduced to detect two markers of infection:
1.Increased levels of bacterial toxins.
2.Increased levels of human inflammatory proteins
and bacterial proteins.
TOPASTM is a simple, painless test, which can be
performed by any health professional in only 7 minutes at
a very reasonable cost.
There are two generations of this test.
1st -Manual
2nd -Automated version.
The TOPASTM (Toxicity Prescreening Assay) is based on the reaction
of bacterial toxins in GCF with a specially developed mixture of
chemical reagents to produce a dose related colour change.

The greater the concentration of toxins in the GCF sample, the

brighter the yellow colour of the assay mixture.

This test is indirect indicator of metabolic activity within the actively

dividing bacteria.
 DIP STICK TEST

• The matrix metalloproteinase‑8 (MMP‑8) test stick is based on the

immunochromatography principle that uses two monoclonal
antibodies specific for different epitopes of MMP ‑8.
• The test stick results can be detected in 5 min.
• The antibody detects both neutrophils and non ‑PMN ‑type MMP ‑8
isoforms.
 PROCEDURE

The GCF sample collected will be placed in a test tube containing 0.5 ml of a buffer at pH
7.4.

When the dip area of dipstick is placed in the extracted sample; the dipstick absorbs liquid,
which starts to flow up the dipstick.

 When the sample contains MMP‑8, it binds to the antibody attached to the latex particles.

The particles are carried by the liquid flow if MMP‑8 is bound to them; they bind to the
catching antibody.

If the concentration of MMP‑8 in the sample exceeds the cutoff value for the test, a positive
line will appear in the result area
Some Commercial Tests under
development
 ẞ- GLUCURONIDASE

A diagnostic kit based on ß- glucuronidase is being commercially

developed by Abbott Laboratories, North Chicago, USA.

It uses a histochemical substrate for the enzyme coupled to a colour

detection system which is released if the enzyme attacks the substrate.
 CYSTEINE AND SERINE PROTEINASES

A test system suitable for chairside use has been developed by Enzyme
System Products/Prototek of Dublin, California, USA.

This system contains the peptide substrates and the 7-amino trifluoro-
methylcoumarin (AFC) leaving group which is considerably more
sensitive than other fluorogenic leaving groups.
 The use of the appropriate derivative of 7-amino-trifluoromethyl coumarin
(AFC) is used to detect proteolytic enzyme activity.

 The enzyme activity splits the substrate and releases AFC.

 This produces a typical green fluorescence that can be detected by

ultraviolet (UV) light. It can also be reacted with cinnamaldehyde to produce
a Schiff purple colour base. The amount of enzyme present is proportional to
the intensity of the fluorescence or colour.
 CHAIR SIDE KITS THAT USES SALIVA

Test Kits Functions

Oral fluid nanosensor test (OFNASET) Detection of multiple salivary proteins
and nucleic acids.
Electronic taste chips Simultaneously monitor several
biomarkers related to periodontal disease

OraQuick Usually detects HIV 1 and HIV 2

Integrated microfluidic platform for Quantification of an oral disease
oral diagnostics biomarker
 ELECTRONIC TASTE CHIPS
• Researchers at Rice University in Houston, Texas, are developing a lab-on-a-chip system,
which will differentiate between healthy and periodontally diseased individuals based on
the CRP levels .
• On the interior regions of the microspheres, sensor array platform is placed where all the
chemical and immunological reactions are performed.
• These microspheres are located on the inverted pyramidal microchambers of microchip.
• A Charge-Coupled Device (CCD) video chip visualizes and captures the various optical
signals generated by the reactions on the microspheres.
• The ETC system has the advantage over the ELISA in having porous beads, which allows
greater number of antibody molecules to capture and thus detect, CRP at extremely low
concentrations
 INTEGRATED MICROFLUIDIC PLATFORM
FOR ORAL DIAGNOSTICS (IMPOD)
• IMPOD, a point-of-care diagnostic test, helps in the rapid quantification of salivary
biomarkers related to oral disease.

• It facilitates hands-free saliva analysis by integrating sample pretreatment with

electrophoretic immunoassays to quickly measure analyse concentrations in minimally
pretreated saliva samples.

• Rapid measurement of levels of the collagen cleaving enzyme MMP-8 in saliva from
healthy and periodontally diseased subjects can be achieved.

• The hand-held IMPOD has been used to rapidly (3–10 minutes) measure the concentrations
of MMP-8 and other biomarkers in small amounts (10 ml) of saliva
 GENETIC TEST KITS
• Periodontitis susceptibility trait test (PST)
• The periodontitis susceptibility trait test is the first genetic susceptibility test for severe
periodontitis.
• It is commercially available.
• It evaluates the simultaneous occurrence of allele 2 at the IL‑1α +4845 and 1β +3954 loci.
• IL‑1 genetic susceptibility may not initiate or cause the disease but rather may lead to
earlier or more severe disease.
• The IL‑1 genetic test can be used to differentiate certain IL ‑1 genotypes associated with
varying inflammatory responses to identify individuals at risk for severe periodontal disease
even before the age of 60.
 MyperioID
• My PerioID test uses saliva to determine a patient’s genetic susceptibility to periodontal
diseases.
• It assesses patients who are at higher risk of more serious periodontal infections.
• This test requires the transportation of saliva samples to a laboratory for results.
 Detects(from human DNA) genetic variation/polymorphism within the IL‑1 gene
 IL‑1 is a major inflammatory mediator
 30–35% of the US population has this genetic variation
 IL‑1 positive individuals tend to have more aggressive and more severe infections
 Determines patients that are most susceptible to severe disease, especially if the patients smoke
 This genetic variation can increase risk for severe disease or tooth loss by 2–7 times when
present.
 NUCLEIC ACID PROBE

• It is a nucleic acid probe assay, developed by Microprobe

corporation, to semiquantitatively detect periodontal
pathogens.
• The plaque samples are collected to test the bacterial load.
• The lysis of bacterial cells takes place by heating, in the
presence of a detergent, to extract their DNA. The DNA thus
obtained, is placed into a multi-well cassette, which is then
placed in a machine with a programmable robotic arm.
• Finally, results are obtained digitally.
 POINT-OF-CARE (POC) TESTING

• Point-of-care (POC) testing can be defined as testing

performed close to the patient at the time care is required.
• POC can revolutionize both periodontal diagnostic and
therapy.
• These tests rely on the detection of a plethora of biomarkers
of disease activity.
• These markers present in saliva, gingival crevicular fluid
(GCF), plaque, or living tissue are quantifiable and indicate
health and disease.
Table
showing
various
available
point-of-
care
devices
Commercially available salivary point-of-care
diagnostics
Commercially available kits using GCF for detecting
host-derived enzymes
commercially available kits for detecting bacterial
protease
 DIAGNOSTICS-LAB-ON-CHIP

• Lab-on-chip is a newer generation of POC technology still

undergoing development.
• It basically integrates and automates all the complexities of a
laboratory procedure onto a computer chip.
• This technology will thus measure multiple biomarkers in a
small sample of plaque, GCF, or saliva.
• It will omit all the requirements of heavy expensive equipment or
trained lab technicians.
• The result will be chair-side, instant, and not subjective.
SUMMARY
 CONCLUSION

• After all these years of intensive research, we still lack a proven diagnostic
test that has demonstrated high predictive value for disease progression,
has an impact on disease incidence - prevalence & is simple, safe , cost-
effective….

• Future application of advanced diagnostic techniques will be of value in

documenting disease activity & treatment options.
 REFERENCES

• Carranza Clinical periodontology Newman, Takei, Klokkevold, Carranza. 13th edition

• Loesche WJ. The identification of bacteria associated with periodontal disease and dental caries by
enzymatic methods. Oral Microbiol Immunol. 1986 Nov;1(1):65-72.
• Loesche WJ, Lopatin DE, Giordano J, Alcoforado G, Hujoel P. Comparison of the benzoyl-DL-arginine-
naphthylamide (BANA) test, DNA probes, and immunological reagents for ability to detect anaerobic
periodontal infections due to Porphyromonas gingivalis, Treponema denticola, and Bacteroides forsythus. J
Clin Microbiol. 1992 Feb;30(2):427-33.
• Shankar S, Nayak R, Mohanty R, Mohanty G, Panda S, Das A. Chairside Diagnostic Aids in
Periodontics: A Review. Indian Journal of Forensic Medicine & Toxicology. 2020 Oct 1;14(4).
• Fatima T, Khurshid Z, Rehman A, Imran E, Srivastava KC, Shrivastava D. Gingival Crevicular Fluid
(GCF): A Diagnostic Tool for the Detection of Periodontal Health and Diseases. Molecules. 2021 Feb
24;26(5):1208.
• Srivastava N, Nayak PA, Rana S. Point of Care- A Novel Approach to Periodontal Diagnosis-A Review. J
Clin Diagn Res. 2017 Aug;11(8):ZE01-ZE06.