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19 Local Factors Contributing to Periodontal Disease

Chapter 16: Local Factors Contributing to Periodontal Disease

Definition of Local Contributing Factors

  • Primary Etiologic Factor: Root cause(s) of the condition that initiates a pathologic effect.
  • Local (Intraoral) Contributing Factor: A secondary factor present in the oral cavity that can act as a disease site for periodontal disease.
    • Specific terms:
    • Individual tooth
    • Specific surface of tooth

Mechanisms for Increased Disease Risk in Local Sites

Table 16-1: Mechanisms

  • Mechanism: Describes local factors that can influence periodontal disease:
    • Local factor that increases plaque biofilm retention: Examples include:
    • Rough edge on a restoration that harbors plaque biofilm
    • Hinders removal of the plaque biofilm with a brush and floss.
    • Local factor that increases plaque biofilm pathogenicity (disease-causing potential): Examples include:
    • Calculus deposits that harbor plaque biofilm.
    • These areas allow the biofilm community to grow uninhibited.
    • Local factor that inflicts damage to the periodontium: Examples include:
    • Ill-fitting dental appliances putting excessive pressure on the gingiva.
    • History of traumatic tooth brushing.
    • Trauma from occlusion or high frenal attachment.

Dental Calculus

  • Definition: Mineralized bacterial plaque biofilm covered by nonmineralized, viable bacterial plaque biofilm on the external surface.
  • Mineralization Process: Begins from 48 hours up to 2 weeks after plaque biofilm formation.

Effects of Calculus on the Periodontium

  • Regularly affects the periodontium negatively by:
    • Maintaining an irregular surface always covered with viable bacteria.
    • Creating larger plaque-retentive irregular ledges on teeth as deposits build up.
    • Altering contours of teeth, which can complicate cleaning.
    • Adhering to roughened and threaded surfaces of implants, potentially initiating host inflammatory responses and leading to loss of osseointegration.

Pathologic Potential of Calculus

  • Significance: Calculus plays a significant role in periodontal disease by:
    • Being always covered with a layer of living bacteria.
    • Aggravating gingival inflammation.
    • Making it difficult to achieve control over gingivitis or periodontitis.
    • Importance of deposit removal cannot be overstated.

Inorganic Portion of Calculus

  • Comprising 70% to 90% of calculus, primarily consisting of:
    • Calcium phosphate
    • Smaller amounts of calcium carbonate and magnesium phosphate.
  • Characteristics:
    • Similar to inorganic components of bone.
    • Displays a dense, radiopaque appearance on radiographs.
    • Using radiographs for calculus detection is not foolproof.

Disadvantages of Using Radiographs to Detect Calculus

  • Limitations include:
    • May not detect small deposits.
    • Provide only two-dimensional images of three-dimensional objects.
    • Different techniques may yield different results.

Organic Portion of Calculus

  • Composes 10% to 30% of overall composition.
  • Includes materials such as:
    • Materials derived from plaque biofilm.
    • Dead epithelial cells.
    • Dead white blood cells.
    • Possible presence of living bacteria.

Crystalline Forms of Dental Calculus

  • Types include:
    • Brushite: Newly formed calculus deposit.
    • Octacalcium phosphate: Primary form in deposits less than 6 months old.
    • Hydroxyapatite: Primary form in deposits older than 6 months.

Supragingival Calculus Deposits

  • Located coronal to the gingival margin.
  • Visible during routine clinical examination.
  • Typically found in localized areas of the dentition, often adjacent to large salivary ducts.
  • Most often irregular with large deposits.

Location and Classification of Calculus Deposits

  • Can exist both supragingivally and extend subgingivally.
  • Sometimes present below gingival margin but absent supragingivally if complete supragingival calculus removal is combined with ineffective subgingival instrumentation.
  • Classified based on location in relation to the gingival margin.

Attachment Mechanisms of Calculus

  • Attachment by Means of Pellicle:

    • Definition: Pellicle is a thin, bacteria-free membrane that forms on tooth surface during late stages of eruption.
    • Most common mode of attachment on enamel.
    • Calculus deposits can be easily removed by tooth brushing.

  • Attachment to Irregularities in the Tooth Surface:

    • Irregularities such as cracks or grooves make deposit removal challenging as they shelter deposits within the tooth defects.

  • Attachment by Direct Contact of the Calcified Component and the Tooth Surface:

    • Matrix of calculus deposits may interlock with inorganic crystals of the tooth, making them difficult to remove.

Tooth Morphology

  • Definition: Study of anatomic surface features of teeth.
  • Features like grooves and concavities are naturally occurring and contribute to difficulty in self-care at sites, leading to gingivitis and periodontitis risk.

Specific Tooth Anomalies

  • Palatoradicular Groove:
    • Described as a developmental anomaly extending from palatal surface to root surface, often seen on maxillary lateral incisors. Difficult to clean and plaque-retentive.
  • Root Concavity:
    • A feature often found on the mesial root surface of maxillary first premolar making self-care challenging if exposed.
  • Cervical Enamel Projection (CEP):
    • Defined as a flat, triangular-shaped projection of enamel which projects towards the direction of furcation and is not easily visualized on radiograph.
  • Enamel Pearl:
    • A well-defined ectopic, spherical enamel deposit found on root surfaces, visually apparent on radiographs, typically on root trunks of molar teeth.

Management of Tooth Anomalies

  • Both CEP and enamel pearls can retain plaque biofilm and increase the likelihood of furcation invasion. Detection is crucial and surgical removal is recommended.

Malocclusion

  • Definition: A developmental anomaly associated with irregular alignment of teeth that predisposes areas to biofilm retention and gingival inflammation.
  • Close, multidisciplinary collaboration among patient, dentist, periodontist, and dental hygienist may be required for management.

Dental Caries

  • Caused by untreated tooth decay, acting as a protected habitat for bacteria. Proper management is paramount for controlling periodontal conditions.

Orthodontic Appliances

  • Tend to harbor plaque and complicate access for brushing and flossing, limiting the physiological self-cleaning mechanisms of the tongue and cheeks.
  • Importance of evaluating periodontal condition at every appointment and collaborating with patients and orthodontists to reinforce good oral health practices.

Dental Restorations as Local Factors

  • Restorations may inadvertently promote adherence and colonization of bacteria, potentially causing periodontal disease or tooth decay.
  • Iatrogenic Factor: Refers to treatment that results in inadvertent adverse outcomes.

Specific Issues with Restorations

  • Overhanging Margins on Restorations: Known as overhangs, these areas are difficult for patients to clean. Recommendations include smoothing margins or removing and replacing restorations.
  • Open Margins on Restorations: Gaps between restoration edges and the natural tooth surface can lead to plaque accumulation and gingival inflammation.
  • Bulky or Overcontoured Crowns/Restorations: These may appear excessively large, trapping bacteria and complicating cleaning efforts. They also contribute to food impaction leading to bacterial growth.

Impact of Faulty Prosthetics and Appliances

  • Prosthesis: A device used to restore missing parts of teeth or jaw tissue, challenging to keep clean as they tend to retain biofilm.
  • Inappropriate Crown Placement: Can cause alveolar bone resorption if margins encroach upon the 2-mm zone coronal to the alveolar crest and may violate the supracrestal tissue attachment, which includes junctional epithelium.

Removable Prosthesis Types

  • Allows for daily cleaning and includes:
    • Removable partial dentures (RPD)
    • Removable complete dentures
    • Implant-supported dentures

Importance of Dental Hygiene for Removable Prosthesis

  • Faulty removable prostheses can impinge on gingival tissue, causing biofilm accumulation and triggering periodontal inflammation. Regular inspections of the intaglio surface and evaluation of denture-bearing areas are essential.

Denture Stomatitis

  • Usually asymptomatic and caused by overgrowth of Candida spp. characterized by a puffy, erythematous mucosal lesion; this condition is reversible with effective mechanical plaque control.

Factitious Injuries

  • Factitious Injury: Damage to oral tissues deliberately inflicted by the patient with premeditated intention.
  • Malingering: Intentional injury to the tissues intending to feign or exaggerate a symptom for gain.

Direct Damage Due to Food Impaction

  • Food wedged between teeth during mastication can:
    • Trigger gingival inflammatory responses
    • Strip gingival tissues away from tooth surfaces
    • Lead to alterations in gingival contour. Education on proper cleaning techniques using interdental brushes, waxed floss, or irrigation is necessary.

Direct Damage from Patient Habits

  • Improper use of plaque biofilm control aids can damage the gingival tissue.
  • Tongue Thrusting: Exerts pressure against teeth and can lead to issues.
  • Mouth Breathing: Dries out gingival tissues.
  • Traumatic Tooth Brushing: Can harm gingival tissues, damage teeth, and cause dehiscence.
  • Oral Jewelry: Increases disease transmission risks, hypersensitivity reactions, nerve damage, and mechanical damage.

Trauma from Occlusion

  • Traumatic occlusion may lead to:
    • Alveolar bone resorption
    • Clinical signs like tooth mobility, sensitivity to pressure, and migration of teeth
    • Radiographic signs like enlarged PDL spaces and angular alveolar bone resorption.

Types of Occlusal Trauma

  • Primary Trauma from Occlusion: Injury to healthy periodontium due to excessive occlusal forces, can be caused by improperly installed prosthetics. Signs include:

    • Wider PDL space
    • Tooth mobility and pain.

  • Secondary Trauma from Occlusion: Injury resulting from normal or excessive occlusal forces applied to previously damaged periodontium, making the affected tooth more susceptible to additional damage.

Parafunctional Occlusal Forces

  • Result from either unconscious or conscious tooth-to-tooth contact occurring when not eating and include:
    • Clenching
    • Bruxism (grinding) of teeth
  • Excessive forces from these behaviors can be managed through occlusal adjustments and protective appliances.