Iatrogenic Factors in Periodontal Disease Prepared by (1).pptx

Periodontics

1. . Napoleon, when advised to consult his physician, allegedly declaimed, "I do not want two diseases - one nature-made, one doctormade ", and marched off

2. IATROGENIC FACTORS IN  PERIODONTAL DISEASE Prepared by Dr Sneha Banerjee

3. Content introduction Definition   Common factors: 1. Margins of the restoration 9. habits and self inflicted injuries 2. Contour and open contact 10. Radiations Therapy 3. Restorative material 4. Design of the removable partial denture 5. Restorative dentistry procedure 6. Malocclusion 7. Orthodontic therapy 8. Extraction of impacted third molar

4. Definition Inadequate dental procedures that contribute to the deterioration of the periodontal tissues are referred to as iatrogenic factors Greek word Iatrogenic – Doctor or Healer Gennen – as a result

5. The oral cavity is an open growth system in which most bacteria can only survive if they adhere to “non-shedding” dental hard surfaces such as teeth, restorations, dental implants or prostheses (see Chapple and Gilbert 2002). 

6. COMMON COMPLAINS Patient Food lodgment Pain Missing teeth malocclusion

7. Restorative materials The presence of any restoration in the mouth, even if of ideal quality, will increase the risk of plaque retention and, as a consequence, periodontal disease. This is for two reasons: no restorative material has a surface energy as low as natural enamel and junctions between the tooth and restoration will retain plaque. junction Reasons Surface energy

8. Restorative materials This study suggests that subgingivally placed NCR, RMGI and giomer restorations can show similar effects on periodontopathogenic bacteria in the treatment of gingival recessions that are associated with noncarious cervical lesions (NCCLs).

9. 1. Margins Of  The Restoration I. Overhanging restoration II. Location of the margin III. Marginal roughness

10. Overhanging Restoration Overhanging dental restorations (ODR) are a major dental health problem. An ODR is defined as an extension of restorative material beyond the confines of a cavity preparation. They have been strongly implicated as an etiologic factor in the progression of periodontal disease and are alarmingly prevalent.

11.   Inhibit the patient’s access to remove accumulated plaque

12. Overhanging margins Change the ecologic balance of the gingival sulcus to an area that favors the growth of disease-associated organisms (predominately gram negative anaerobic species) at the expense of the health associated organisms (predominately gram-positive facultative species

13. B) Location of  the gingival margin Subgingival margins Severe gingivitis and deep pockets Equigingival margins Less severe gingivitis Supragingival margins Normal as in natural teeth

14. Surface roughness is an intrinsic feature of dental materials, which can be altered by polishing, scaling, brushing, condensing, glazing and finishing. A threshold surface roughness of 0.2 microns exists above which bacterial adhesion will increase. Sources of marginal roughness include Grooves and scratches in the surface of even a carefully polished restoration ex: porcelain or gold restorati o n C) Marginal Roughness  

15. Prosthetic dentistry and periodontics  There is a strong association between prosthetic dentistry and periodontics  Periodontal health plays an important role in the longevity of prosthodontic restorations. 

16. Internal fit and marginal adaptation are the key criteria for the long-term clinical success of any restorations  subgingival margins typically shows a gap of 20-40 um between the margin of the restoration and the unprepared tooth surface that favors bacterial plaque colonization ii. Inadequate marginal fit of the restoration

17. iii. The gap that exposes the rough prepared tooth structure following the dissolution of the luting cement at the restoration margins SEM photomicrograph of the cervical margin of a 5-year old porcelain veneer (P) showing a small marginal defect and a border of roughened porcelain (arrows). (G, gingiva; C, luting composite

18. 2. Contour and   Open Contacts I. Overcontoured Crowns Buccal and lingual contours Occlusal contours II. Inadequate interproximal embrasure

19. I. Overcontoured Crowns   Overcontoured crowns and restorations tend to accumulate plaque and possibly prevent the self-cleaning mechanisms of the adjacent cheek, lips, and tongue

20. a) Buccal and  Lingual Contours Over-contoured Under-contoured Prevent self cleansing mechanism of the cheeks, lips and tongue Does not have that much destructive effect

21. U nder contoured  restorations with absent or shallow buccal deflection ridge are said to cause gingival trauma due to injury by rough food

22. b) Occlusal Contour b) Occlusal Contours  Established by marginal ridges and related developmental grooves. Normally they deflect food away from the inter proximal spaces

23. Occlusal Contours Inappropriate  occlusal contours leads to Food impaction Plaque retention Food impaction is defined as the forceful wedging of the food into the periodontium by occlusal forces Cusps that tend to forcibly wedge food into interproximal embrasures are known as plunger cusps.

24. Occlusal Contours Factors   leading to food impaction  Uneven occlusal wear.  Open contact area as a result of the loss of proximal support or from extrusion  Congenital morphologic abnormalities  Improperly constructed restorations

25. Biologic Width and Gingival Biotype Considerations in Fixed Prosthetic Restorations and Periodontal Health Biologic width is a natural seal that is present around the teeth, protecting the alveolar bone from infection and diseases The biological width is defined as the dimension of the soft tissue that is attached to the portion of the tooth coronal at the crest of the alveolar bone 

26. The biologic width is an essential space that must be maintained to ensure periodontal health in any dental prosthetic restorations  an iatrogenic fixed dental prosthesis that is constructed in violation of the biologic width predisposes the development of subgingival caries in the involved teeth and results in an uncontrolled inflammatory process and periodontal tissue destruction

27. Nevins and Skurow mentioned that, in cases where the subgingival margins are indicated, the dentist should not disrupt the junctional epithelium or connective tissue during tooth preparation and taking an impression. They also suggested limiting the subgingival margin extension to 0.5–1.0 mm, as it is impossible for the dentist to detect where the sulcular epithelium ends and the junctional epithelium begins.

28. Inadequate interproximal  embrasure associated with papillary inflammation

29. The undersurface of   pontics in fixed bridges The undersurface of   pontics in fixed bridges should barely touch the mucosa. Access for oral hygiene is inhibited with excessive pontic to tissue contact.

30. Design of  Removable partial denture Removable partial dentures   favor plaque accumulation resulting in: gingival inflammation periodontal pocket formation mobility of the abutment teeth.

31. Partial dentures that  are worn during both night and day induce more plaque formation than those worn only during the daytime The presence of removable partial dentures induces both quantitative and qualitative changes in dental plaque promoting the emergence of spirochetal microorganisms

32. Restorative Dentistry    The use of  rubber dam clamps, matrix bands, and burs in such a manner as to lacerate the gingiva results in varying degrees of mechanical trauma producing transient injuries that generally undergo repair

33. Forceful packing of  a gingival retraction cord Forceful packing of  a gingival retraction cord into the sulcus to prepare subgingival margins on a tooth or for the purpose of obtaining an impression may mechanically injure the periodontium and leave behind impacted debris capable of causing a foreign body reaction.

34. 6. Malocclusion Irregular alignment of  teeth results in more difficult plaque control Several authers found a positive correlation between crowding & periodontal disease but others didn’t find any correlation.

35. In orthodontic treatment, teeth are moved in to new positions and relationships and the soft tissue and underlying bone are altered to accommodate changes in esthetics and function. Few of the malocclusions which affect the periodontium such as anterior deep bite can cause stripping of the labial gingiva of lower anteriors and lingual gingiva of upper anteriors . Anterior cross bite can cause localized gingival recession & mobility of the affected tooth. Correcting these malocclusions with orthodontic treatment will help to improve the periodontal status and overall health of an individual.

36. Occlusal Disharmonies Restorations  that doesn’t conform to the occlusal pattern of the dentition may cause injury to the supporting periodontal tissues (traumatic occlusion – T.F.O.) Histological features of the periodontium of a tooth subjected to T.F.O. :  widened PDL space,  Reduction in the number of collagen content in oblique and horizontal fibers  increase in vascularity and leukocyte infiltration,  increase in the number of osteoclasts on bordering alveolar bone.

37. 7. Periodontal complications  associated with orthodontic therapy I. Direct effect II. Indirect effect

38. I. Indirect Effect   i . Favoring plaque retention and food debris. ii. Modifying the  gingival ecosystem resulting in gingivitis An increase in  Prevotella Odontolyticus  Prevotella Intermedia  Actinomyces Odontolyticus  Aggregatibacter actinomycetemcomitans With the decrease in facaulitative microorganisms

39. D irect effect   i . Creating excessive and/or unfavourable forces on teeth and supporting structures Excessive force produce :  necrosis of PDL and adjacent alveolar bone  increase the risk of apical root resorption Risk factors for root resorption include : magnitude of force ,duration of treatment , continous versus intermittent force Direction of tooth movement

40. Orthodontic bands   Orthodontic bands  placed on newly erupted permanents with still attached junctional epithelium on enamel will result in apical migration & proliferation of the junctional epithelium and an increased incidence of gingival recession

41. Other Effects   Surgical exposure of impacted teeth and orthodontic-assisted eruption has the potential to compromise the periodontal attachment on adjacent teeth . However , those teeth have more than 9o% of their attachment remains intact

42. It has  been reported that the dentoalveolar gingival fibers that are located within the marginal and attached gingiva are stretched when teeth are rotated during orthodontic therapy Surgical removal of these gingival fibers in combination with a brief period of retention may reduce the incidence of relapse after orthodontic treatment intended to realign rotated teeth

43. Failure to replace  posterior teeth After the extraction of mandibular 1st molar with the failure to replace : 1) the initial change is a mesial drifting and tilting of the mandibular second and third molars 2) extrusion of the maxillary first molar 3) As the mandibular second molar tips mesially , its distal cusps extrude and act as plunger 4) The distal cusps of the mandibular second molar wedge between the maxillary first and second molars and open the contact by deflecting the maxillary second molar distally.

44. 8) Extraction of  impacted third molars Extraction of impacted  third molars often results in T he creation of vertical defects distal to the second molars. However this iatrogenic effect is unrelated to flap design *But it’s related to presence of plaque , bleeding on probing , pathologically widened follicle , inclination of third molar , root resorption of 2nd molar * It appears to occur more often when third molars are extracted in individuals older than 25 years.

45. Another consequence  of removal of third molars include permanent paresthesia (numbness of the lip, tongue, and cheek), d.t injury of the lingual nerve passing distal to third mandibular molar

46. 9. Habits and  Self Inflicted Injuries I. Tooth brush  trauma 1. Acute  Erosions & diffuse erythema  Ulcers  Acute gingival abscess forcefully embeded tooth brush bristle history : Signs of acute gingival abrasion are frequently noted when the patient first uses a new brush 2. Chronic  Buccal and lingual recession and attachment loss  Cervical abrasion

47. II . Chemical  Injury 1) allergic inflammatory states, the gingival changes range from simple erythema to painful vesicle formation and ulceration. E.x . mouthwashes, dentifrices, or denture materials 2) nonspecific injurious effect of chemicals on the gingival tissues. * topical application of corrosive drugs such as aspirin , phenol or silver nitrate

48. III. Tobacco use  It results in : 1) oral leukoplakia 2) Increased incidence of gingival recession, 3)cervical root abrasion, and root caries 4) high incidence of severe periodontitis

49. 10. Radiation Therapy Radiation therapy has cytotoxic effects on both normal and malignant cells The typical total dose of radiation for head and neck tumors is in the range of 5000 to 8000 centiGrays ( cGy = 1rad) The total dose of radiation is given in partial incremental doses (Fractionation where the typical dose administrated is in the range of 100 to 1000 cGys per week). this helps to minimize the adverse effects of the radiation while maximizing the death rate of the tumor cells.

50. Radiation therapy induces  Obliterative Endarteritis resulting in i . Soft tissue ischemia and fibrosis ii. Hypo vascular and hypoxic bone iii. Osteoradionecrosis iv. Dermatitis and mucositis v. muscle fibrosis and trismus (restricting access to oral cavity) vi. Xerostomia (greater plaque accumulation) vii. Caries viii. periodontal attachment loss and teeth loss ix. Greater risk to periodontal infections

51. How to prevent   1. The severity of the mucositis can be reduced by asking the patient to avoid secondary sources of irritation to the mucous membrane, such as smoking, alcohol, and spicy foods. 2. Use of  a chlorhexidine digluconate mouthrinse may help reduce the mucositis. However, chlorhexidine mouthrinses having a high alcohol content that may act as an astringent, which dehydrates the mucosa, thereby intensifying the pain.

52. 3. Fluoride application,  effective oral hygiene measures and frequent dental examination. 4. Consult the oncologist before any surgical or periodontal procedure to decrease incidence of osteoradionecrosis 5. Prophylactic antibiotics to avoid osteomyilitis 6. Restricted use of local anesthetic with vasoconstrictor. 7. Hyperbaric oxygen therapy for treatment of osteoradionecrosis

53. Complications of the  Use of Laser in Periodontology Nd:YAG (neodymium-doped yttrium   aluminum garnet; Nd:Y3Al5O12) Pitting and crater formation in cementum 2. Exposure of dentinal tubules, and cementum “peeling” 3. A reduced attachment of fibroblasts to Nd:YAG laser treated cementum was observed

54. In conclusion the  use of the Nd:YAG laser in periodontal treatment is restricted to the area of the soft tissue management. No safe removal of calculus is possible using a Nd:YAG laser.