Periodontal Risk Assessment: Local and Systemic Factors

Primary etiology

Bacterial plaque

Secondary etiology

Local and systemic factors

initiate

There is no concrete evidence that any of the contributing (secondary) factors can ___ periodontal disease by themselves; simply, they enhance the ability/virulence of the bacterial plaque to cause periodontal disease.

Local factors that make plaque removal more difficult

• Calculus

• Caries

• Iatrogenic

• Anatomical features

• Trauma

Primary occlusal trauma

injury to a healthy periodontium resulting from excessive occlusal forces

Secondary occlusal trauma

injury to the periodontium from normal occlusal forces applied to a periodontium previously damaged by periodontitis

w/out

Occlusal trauma __ inflammation will not cause attachment lost

w/

Occlusal trauma __ inflammation will cause attachment loss

gingival margin trimmer (GMT)

Caries which approximates the __ can complicate plaque removal.

repaired

Lesions should be __ early in therapy to allow easier plaque removal.

Iatrogenic factors

• Open margins

• Overhanging margins

• Open contacts/food Impaction

• Over contoured restorations

Tooth position

• Crowding

• Tipping

• Root proximity

Anatomical factors

__ such as furcation involvement, enamel pearls, enamel projections and developmental grooves and concavities can complicate oral hygiene.

Furcation involvement

bone loss between the roots of multi-rooted teeth

Enamel pearls

small masses of excess enamel on the surface of teeth located APICALLY to the CEJ

1.1-5.7%

___ of permanent molars have enamel pearls

75%

__ of maxillary third molars have enamel pearls

Enamel projections

Extension of enamel beyond the cervical margin

28.6%

___ of Mandibular molars have enamel projections

17%

____ Of maxillary molars have enamel projections

Concavities

Dental floss may be less effective than an interdental brush on long root surfaces with _____.

Interdental brush

If there are concavities you may want to recommend a

Mandibular molar furcation concavity

Maxillary molar furcation concavity

Root amputation

A surgical procedure that is used to remove one or more roots of a multirooted tooth without removing the crown (maxillary)

Hemisection

Surgical separation of a multirooted tooth through the furcation area (mandibular)

Developmental grooves

Fine depressed lines in the enamel of a tooth that mark the union of the loves of the crown.

5.6%

_ of maxillary lateral incisors have developmental grooves

3.4%

__ of maxillary central incisors have developmental grooves

Soft tissue

__ defects such as inadequate attached gingiva, clefts, enlargements and craters can complicate oral hygiene.

mucogingival involvement (MGI)

areas with no attached gingiva present, the PPD will present below the mucogingival junction (worse than defect)

Mucogingival involvement (MGI)

Total gingival - Free gingival

<1 mm yes to MGI

Clefts

Lack of oxygen can lead to receding, openings, cracks due to inflammation, etc

Gingival enlargements

Gingival overgrowths that are generalized or localized

Soft tissue craters

Occur after periodontal surgery, dips down cervically and usually self corrects

Systemic conditions that affect periodontal disease

• Endocrine Conditions

• Obesity

• Hematologic Disorders

• Neutrophil Disorders

• HIV positive

• Medications

• Stress

• Smoking

• Nutrition

• Heredity

Diabetes and hormones

Endocrine conditions such as ___ can affect periodontitis

Hormonal conditions

• Puberty

• Pregnancy

• Estrogen deficiency

Puberty gingivitis

• peaks at 11 to 13 years of age, self limiting w/ age

• related to hormonal changes creating a more favorable environment for pathogens

• both male and female

Pregnancy gingivitis

Increased hormone levels in gingival crevicular fluid associated with dramatic increases in P. intermedia, which use hormones as growth factors.

P. intermedia

In pregnancy gingivitis, increased hormone levels in gingival crevicular fluid associated with dramatic increases in ___, which use hormones as growth factors.

Estrogen deficiency/osteoporosis

• Bone mass peaks age 20 - 30

• Reduction accelerates at menopause

• Estrogen is protective

• Estrogen deficiency is a possible modifying factor in alveolar bone loss

estrogen replacement therapy (ERT)

Reduces alveolar bone loss post menopause

Diabetes

• Increased incidence of gingivitis /periodontitis

• Defective PMN chemotaxis

• Enlarged gingiva

• Periodontal abscesses

Attachment loss

Diabetics have a way higher chance of

3mm

Periodontitis is defined as __ LOA

4mm

Periodontitis is defined as ___ probing depth

NHANES III database

Showed how obesity will increases probability of periodontal disease

Hematologist disorders

Conditions of blood

*Anemia

*Sickle cell anemia

Acute leukemia

67% change for gingival enlargement and 18% for bleeding

Leukemia

Gingival enlargement and bleeding

Chronic leukemia

Rare chance for gingival enlargement and 4% for gingival bleeding

Neutrophil disorders

The neutrophil is the first line of defense to combat acute bacterial infection.

____ results in severe periodontitis.

Neutrophil disorders (depressed chemotaxis)

- Chediak - Higashi Syndrome

- Diabetes mellitus

- Prediabetic

- Down's syndrome

- Lazy leukocyte syndrome

- Papillon - Lefèvre syndrome

- Malnutrition

HIV associated periodontal diseases

• Linear gingival erythema

• Necrotizing gingivitis

• Necrotizing periodontitis

No deep pockets

The difference between periodontitis and necrotizing periodontitis is that in necro there are ___ because gingival is at bone level

Linear gingival erythema

• persistent, linear, easily bleeding, erythematous gingivitis

• possible etiologic role for candidial species

Necrotizing gingivitis and periodontitis

painful infections characterized by tissue ulceration, swelling and sloughing of dead epithelial tissue from the gingiva, and fetid oral odor

Drug manifestations w/ periodontitis

• Phenytoin (Dilantin)

• Cyclosporine

• Nifedipine (Calcium Channel Blockers)

• Cannabis

• Oral contraceptives

-pine

calcium channel blockers

Phenytoin (Dilantin)

• enlargement occurs in about 50% of patients

• genetic predisposition suspected

Interdental, facial

Phenytoin enlargement usually occurs first at

Phenytoin (Dilantin)

__ evidence links pathogenesis to direct effect on fibroblasts, inactivation of collagenase, and plaque-induced inflammation

Cyclosporine

Immunosuppressant

• more vascularized than phenytoin induced enlargements

• 20-70% occurrence

• plasma cell infiltrate suggests hypersensitivity response

Cyclosporine

____ is more vascularized than phenytoin induced enlargements

plasma cell

Cyclosporine causes ___ infiltrate suggests hypersensitivity response

57%

___ had a positive relation between stress and periodontitis

29%

___ found mixed results between stress and periodontitis

14%

___ found negative relation between stress and periodontitis

How stress affects periodontitis

1) poor oral hygiene

2) alter immune response

• Neutrophil impairment

• Monocyte upregulation

Smoking

Important periodontal risk factor

• Increased incidence and severity of periodontitis

• Poorer response to therapy

• Associated with NUG

• Nicotine can impair neutrophil phagocytosis

• Decreased bleeding on probing

Bleed

Smokers do not ___ as much a non smokers (an important response)

nutritional deficiencies

Efforts to associate periodontal disease with ___ have yielded conflicting results.

lowers

In theory, poor nutrition __ resistance to periodontal disease.

Poor nutrition may slow the healing process.

Low serum calcium and periodontal disease

Results suggest that low dietary intake of calcium results in more severe periodontal disease

40%

Identical twins studies suggest that more than __ of the clinical signs of disease severity are the result of genetic factors.

Hereditary gingival fibromatosis

rare benign oral condition characterized by slow and progressive enlargement of both maxillary and mandibular attached gingiva

IL-1 Genotype

What is the genetic marker for perio?

30%

Those positive w/ IL-1 genotype had > ___ mean bone loss compared to those w/out IL-1 genotype