Local Systemic Factors

Primary Etiology: bacterial plaque

Secondary Etiology: local and systemic factors

  • No concrete evidence that any of the contributing (secondary) factors can initiate periodontal disease by themselves

    • They enhance the ability/virulence of the bacterial plaque to cause periodontal disease

  • Primary and secondary etiologic factors should be listed on the Baseline form under risk assessment

Local Factors: make plaque removal more difficult

  • Calculus

  • Caries

  • Iatrogenic

  • Anatomical features

  • Trauma

Supragingival Calculus

  • 70-90% inorganic

  • 75.9% calcium phosphate

  • 4 main crystal forms

  • 58% hydroxyapatite

21% magnesium whitlockite

  • 12% octacalcium

  • 9% brushite

  • Hampers plaque removal

Subgingival Calculus

  • Similar composition as supra

  • More mag. whitlockite

  • No salivary proteins

  • Higher calcium to phosphate ratio

  • Harder to remove

  • Hampers plaque removal

Caries

  • Caries which approximated the gingival margin can complicate plaque removal

  • Lesions should be repaired early in therapy to allow easier plaque removal

Iatrogenic Factors

  • Open margins

  • Overhanging margins

  • Open contacts/food impactions

  • Over contoured restorations

Tooth Positions

  • Crowding

  • Tipping

  • Tooth proximity

Tooth Associated Anatomical Factors

  • Furcation involvement, enamel pearls, enamel projections and developmental grooves and concavities

Furcation Involvement
furcation
Enamel Pearls

  • 1.1 to 5.7% of permanent molars

  • 75% on maxillary third molars

    enamel pearls
Enamel Projections

  • 28.6% of mandibular molars

  • 17% of maxillary molars

    enamel projections
Concavities
Developmental Grooves

  • 5.6% of maxillary lateral incisors

  • 3.4% of maxillary central incisors

    developmentalgrooves

Soft Tissue Anatomical Factors

  • Inadequate attached gingiva, clefts, enlargements and craters

Clefts
clefts
Gingival Enlargements
gingival enlargements
Soft Tissue Craters
craters

Systemic Conditions and Periodontal Disease

  • Endocrine Conditions

  • Hematologic Disorders

  • Neutrophil Disorders

  • Smoking

  • Medications

  • Nutrition

  • Stress

  • Heredity

  • Obesity

Endocrine Conditions

  • Diabetes

  • Hormonal

Hormonal Conditions

  • Puberty

  • Pregnancy

  • Estrogen deficiency

Puberty Gingivitis

  • Peaks at 11-13 years of age

  • Related to hormonal changes

  • 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

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

Diabetes

  • Increased incidence of gingivitis/periodontitis

  • Defective PMN chemotaxis

  • Enlarged gingiva

  • Periodontal abscesses

  • 2,273 Pima Indians

    • 60% prevalence with diabetes

    • 36% prevalence without diabetes

Obesity and Periodontal Disease

  • Significant association for young group (18-24)

  • OR 1.0 for BMI 18.5-24.9 kg/m2 (reference)

  • OR 1.76 for BMI > 30 kg/m2 (P<0.01)

  • OR 0.21 for BMI < 18.5 kg/m2 (P<0.01)

  • OR 2.27 for high waist circumference (P<0.001)

Hematologic Disorders

Leukemia

  • Gingival Enlargement

    • 4% overall

    • Rare for chronic

    • 67% acute monocytic

  • Gingival Bleeding

    • 18% acute

    • 4% chronic

Neutrophil Disorders

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

  • Neutrophil dysfunction results in severe periodontitis

Drug Manifestations

  • Phenytoin (Dilantin)

  • Cyclosporine

  • Nifedipine (Calcium Channel Blockers)

  • Cannabis

  • Oral contraceptives

Phenytoin (Dilantin)

  • Enlargement occurs in about 50% of patients

  • Genetic predisposition suspected

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

Nifedipine

  • Enlargement occurs in 20% of patients taking nifedipine

  • Enlargement also seen with other calcium-channel blockers (Amlodipine)

Cyclosporine (Immunosuppressant)

  • More vascularized than phenytoin induced enlargement

  • 20-70% occurence

  • Plasma cell infiltrate suggests hypersensitivity response

HIV Associated Periodontal Disease

  • Linear gingival erythema

  • Necrotizing gingivitis

  • Necrotizing periodontitis

Linear Gingival Erythema

  • Persistent, linear, easily bleeding, erythematous gingivitis

  • Possible etiologic role for candidial species

    linear

Necrotizing Gingivitis and Periodontitis

gingivitisperiodontitis

Stress and Periodontal Disease

  • Systematic review

  • 14 of 58 articles analyzed

  • No meta-analysis

  • 57% found a positive relation

  • 29% found a positive and negative relation

  • 14% found a negative relation

Possible Biologic Mechanisms

  • Poorer Oral Hygiene

  • Stress may 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

Nutritional Factors

  • Efforts to associate periodontal disease with nutritional deficiencies have yielded conflicting results

  • In theory, poor nutrition lowers resistance to periodontal disease

  • Poor nutrition may slow the healing process

  • Conclusion: results suggest that low dietary intake of calcium results in more severe periodontal disease

Genetics

  • Identical twins studies suggest that more than 40% of the clinical signs of disease severity are the result of genetic factors

Hereditary Gingival Fibromatosis