Hirsch R S, Clarke N G
Aust Dent J. 1989 Dec;34(6):548-58. doi: 10.1111/j.1834-7819.1989.tb04662.x.
In current clinical practice, a differential diagnosis of severe localized periodontal lesions is rarely made; such lesions are considered to be manifestations of periodontitis caused by specific microbes from the commensal oral flora. However, deep seated lesions of the periodontium which are in communication with the alveolar crest, are well documented periodontal consequences of pulpal pathoses and can mimic the signs and symptoms of 'periodontitis'. The very low incidence of tooth-threatening periodontal disease in ancient and modern man is revealed when differential diagnoses are used in the examination of alveolar defects in anthropological materials and when epidemiological studies use more appropriate indices. However, no periodontal index to date has incorporated a differential diagnosis between gingival and pulpal causes of alveolar bone loss. The gingival and periodontal signs of severe localized periodontal lesions are reviewed and the imprecise nature of current clinical diagnostic tests (radiography, 'pulp testing', darkfield microscopy, bleeding on probing, periodontal probing) is discussed. None of these tests is able to detect disease activity and cannot be used to predict future patterns of disease behaviour. However, the commonly held belief that the tests are accurate has resulted in most severe periodontal lesions being falsely labelled as periodontitis. Failure to carry out differential diagnosis of severe periodontal lesions has resulted in the instigation of periodontal therapy for many lesions of non-gingival origin. Whenever severe localized lesions of the periodontium are detected, the differential diagnosis between pulpal and periodontal origins should be made. The results of diagnostic tests in current use should be interpreted with extreme caution; clinicians are left to exercise their judgment based on consideration of all the available evidence.
在当前的临床实践中，很少对严重局限性牙周病变进行鉴别诊断；此类病变被认为是由口腔共生菌群中的特定微生物引起的牙周炎表现。然而，与牙槽嵴相通的牙周深部病变，是牙髓病变已被充分记录的牙周后果，可模仿“牙周炎”的体征和症状。当在人类学材料中对牙槽骨缺损进行检查时采用鉴别诊断，以及在流行病学研究中使用更合适的指标时，就会发现古今人类中威胁牙齿的牙周疾病发病率极低。然而，迄今为止，尚无牙周指数纳入对牙槽骨丧失的牙龈和牙髓病因之间的鉴别诊断。本文回顾了严重局限性牙周病变的牙龈和牙周体征，并讨论了当前临床诊断测试（放射照相、“牙髓测试”、暗视野显微镜检查、探诊出血、牙周探诊）的不精确性。这些测试均无法检测疾病活动，也不能用于预测疾病未来的行为模式。然而，人们普遍认为这些测试是准确的，这导致大多数严重牙周病变被错误地诊断为牙周炎。未能对严重牙周病变进行鉴别诊断，导致许多非牙龈源性病变接受了牙周治疗。每当检测到严重的局限性牙周病变时，都应进行牙髓和牙周病因的鉴别诊断。对于目前使用的诊断测试结果，应极其谨慎地进行解读；临床医生需根据对所有现有证据的考虑来行使自己的判断力。
