Annual Periodontal Review and Part 1 ABP Board Preparation ... · PDF fileAnnual Periodontal...

Annual Periodontal Annual Periodontal Review and Part 1 Review and Part 1

ABP Board ABP Board Preparation CoursePreparation Course

Francis G. Serio, D.M.D., M.S., M.B.A., Francis G. Serio, D.M.D., M.S., M.B.A., F.I.C.D., F.A.C.D.F.I.C.D., F.A.C.D.

Diplomate, American Board of Diplomate, American Board of Periodontology, 1992Periodontology, 1992

Associate Dean for Clinical AffairsAssociate Dean for Clinical Affairsand Professorand Professor

East Carolina University School of Dental East Carolina University School of Dental MedicineMedicine

Greenville, North Carolina USAGreenville, North Carolina USA

Disclosure StatementDisclosure StatementFrancis G. Serio, DMD, MS, MBAFrancis G. Serio, DMD, MS, MBA

�� LexiLexi--CompComp-- Manual of Clinical PeriodonticsManual of Clinical Periodontics

�� Oral B Guest Lecture Board, P&G Guest Oral B Guest Lecture Board, P&G Guest Lecture BoardLecture Board

�� Maryland Part 1 Board Review CourseMaryland Part 1 Board Review Course

�� LSU Part 2 Board Review CourseLSU Part 2 Board Review Course

MultifactorialMultifactorialInfectionsInfections

Current ConceptsCurrent Conceptsofof

RiskRisk

RISK: RISK: The likelihood that a The likelihood that a

person will get a disease person will get a disease in a specified time period.in a specified time period.

RISK FACTOR: RISK FACTOR: The characteristics of The characteristics of individuals that place individuals that place

them at increased risk for them at increased risk for getting a disease.getting a disease.

Risk factor is defined as Risk factor is defined as ““any any characteristic, behavior, or characteristic, behavior, or

an exposure with an an exposure with an association to a particular association to a particular disease. The relationship is disease. The relationship is

not necessarily causal in not necessarily causal in naturenature……””Garcia, Nunn, Dietrich, 2009Garcia, Nunn, Dietrich, 2009

RISK ASSESSMENT: RISK ASSESSMENT: The process of predicting The process of predicting

an individualan individual’’s s probability of getting a probability of getting a

disease.disease.

RISK INDICATORS: RISK INDICATORS: Probable or putative risk Probable or putative risk

factors that have been identified factors that have been identified in crossin cross--sectional studies but not sectional studies but not confirmed through longitudinal confirmed through longitudinal

studies.studies.

Need a susceptible hostNeed a susceptible host--risk factors contribute to, but risk factors contribute to, but

do not directly cause, the do not directly cause, the initiation or progression of initiation or progression of

disease.disease.

RiskRiskAssessmentAssessment--

The new paradigmThe new paradigm

Assessing RiskAssessing Risk

�� AAP Risk Assessment ToolAAP Risk Assessment Tool-- www.perio.orgwww.perio.org

�� PreviserPreviser-- www.previser.comwww.previser.com

Garcia RI, Nunn ME, Dietrich T. Garcia RI, Nunn ME, Dietrich T. Risk calculation and periodontal Risk calculation and periodontal

outcomes. Periodontol outcomes. Periodontol 2000.2009;50:652000.2009;50:65--77. 77.

Current View of Current View of Risk Factors for the Risk Factors for the Periodontal DiseasesPeriodontal Diseases

The Pathogenesis ParadigmThe Pathogenesis ParadigmFrom Page RC, Kornman KS, Periodontol 2000, 1997;14:9From Page RC, Kornman KS, Periodontol 2000, 1997;14:9--11.11.

Local Risk FactorsLocal Risk Factors

�� PlaquePlaque

�� CalculusCalculus

�� Anatomic factorsAnatomic factors

�� Occlusal factorsOcclusal factors

�� Restorative factorsRestorative factors

�� Other factorsOther factors

PlaquePlaquea.k.a. Biofilma.k.a. Biofilm

Biofilm (plaque) is Biofilm (plaque) is necessary but not necessary but not

sufficient to produce sufficient to produce periodontal periodontal

inflammation.inflammation.

Common Periodontal Common Periodontal PathogensPathogens

�� Aggregatibacter actinomycetemcomitansAggregatibacter actinomycetemcomitans�� Campylobacter rectusCampylobacter rectus�� Eikenella corrodensEikenella corrodens�� Fusobacterium nucleatumFusobacterium nucleatum�� Peptostreptococcus microsPeptostreptococcus micros

Common Periodontal Common Periodontal PathogensPathogens

�� Prevotella intermediaPrevotella intermedia�� Porphyromonas gingivalisPorphyromonas gingivalis�� Streptococcus intermediusStreptococcus intermedius�� Tannerella forsythia (B. forsythus)Tannerella forsythia (B. forsythus)�� Treponema Treponema sp.sp.

BiofilmsBiofilmsFrom Socransky SS, Haffajee AD. Periodontol 2000, From Socransky SS, Haffajee AD. Periodontol 2000,

2002;28:122002;28:12--55.55.

Calculus CompositionCalculus Composition�� CalciumCalcium�� PhosphorusPhosphorus�� CarbonateCarbonate�� Na, Mg, KNa, Mg, K�� Hydroxyapatite (CaHydroxyapatite (Ca55(PO(PO44))3 3 x OH) is major x OH) is major

crystal form in mature calculus. Whitlockite crystal form in mature calculus. Whitlockite isthe most common form in subgingival isthe most common form in subgingival calculus.calculus.

�� Also has octacalcium phosphate (CaAlso has octacalcium phosphate (Ca44H(POH(PO44))33 x x 2H2H22O)O),, whitlockite (whitlockite (BB--CaCa33(PO(PO44))22, and brushite , and brushite (CaH(PO(CaH(PO44) x 2H) x 2H22O).O).

CalculusCalculusMechanisms of AttachmentMechanisms of Attachment

�� Secondary cuticle (organic pellicle that Secondary cuticle (organic pellicle that also calcifies).also calcifies).

�� Mechanical locking into irregularities in Mechanical locking into irregularities in cemental surface.cemental surface.

�� Close adaptation of calculus undersurface Close adaptation of calculus undersurface depressions to unaltered cementum depressions to unaltered cementum surfaces.surfaces.

�� Bacterial penetration of cementum (not Bacterial penetration of cementum (not universally accepted).universally accepted).

CalculusCalculus�� MandelMandel-- JCP, 1986JCP, 1986-- Excellent review on Excellent review on

calculus. calculus. ““Subgingival calculus contributes Subgingival calculus contributes significantly in the chronicity and progression significantly in the chronicity and progression of the disease, even if it can no longer be of the disease, even if it can no longer be considered as responsible for initiation.considered as responsible for initiation.””

�� GreensteinGreenstein-- JP, 1992, JADA, 2000JP, 1992, JADA, 2000--Comprehensive reviews of scaling and root Comprehensive reviews of scaling and root planing and other aspects of nonplaning and other aspects of non--surgical surgical therapy.therapy.

Total Calculus Total Calculus Removal: An Removal: An

Attainable Objective?Attainable Objective?Kepic, OKepic, O’’Leary and KafrawyLeary and Kafrawy-- J Periodontol J Periodontol

1990;61:161990;61:16--20.20.

Clinical Significance of Clinical Significance of NonNon--surgical Periodontal surgical Periodontal Therapy: An EvidenceTherapy: An Evidence--

Based PerspectiveBased PerspectiveJ Clin Periodontol 2002;29(Suppl 2):5J Clin Periodontol 2002;29(Suppl 2):5--32.32.

Furcation AnatomyFurcation AnatomyBower RC, J Periodontol 1979;50:23Bower RC, J Periodontol 1979;50:23--25 and 25 and

1979;50:3661979;50:366--374.374.

�� 81% of maxillary and mandibular first 81% of maxillary and mandibular first molars have furcation entrances molars have furcation entrances << 1 mm.1 mm.

�� 58% of furcation entrances < 0.75 mm.58% of furcation entrances < 0.75 mm.�� Curette widths range from 0.7Curette widths range from 0.7--1.0 mm.1.0 mm.

Furcation AnatomyFurcation AnatomyBower, 1979Bower, 1979

Cervical Enamel ProjectionsCervical Enamel ProjectionsMasters DH, Hoskins SW. J Masters DH, Hoskins SW. J Periodontol 1964;35:49Periodontol 1964;35:49--53.53.

�� Cervical enamel projections were Cervical enamel projections were found in > 90% of mandibular found in > 90% of mandibular isolated furcation involvements.isolated furcation involvements.

Cervical Enamel ProjectionsCervical Enamel Projections

Restorative FactorsRestorative Factors

�� Subgingival marginsSubgingival margins

��OverhangsOverhangs

�� Inadequate embrasuresInadequate embrasures

Restorative FactorsRestorative Factors

��Open marginsOpen margins

��Marginal ridge relationshipsMarginal ridge relationships

��Root surface cariesRoot surface caries

OverhangsOverhangs�� LangLang-- JCP 1983JCP 1983-- debtdebt--ridden dental studentsridden dental students-- 1 1

mm overhangs harbored blackmm overhangs harbored black--pigmented pigmented BacteroidesBacteroides even with good plaque control.even with good plaque control.

�� Jeffcoat and HowellJeffcoat and Howell-- JP 1980JP 1980-- the more severe the more severe the periodontal disease, the greater the role of the periodontal disease, the greater the role of the overhang appeared.the overhang appeared.

�� BrunsvoldBrunsvold-- JCP 1990JCP 1990-- at least 25% of at least 25% of restorations and 33% of patients had restorations and 33% of patients had overhangsoverhangs…….and he was optimistic!!!.and he was optimistic!!!

OverhangsOverhangs

�� PackPack-- JCP 1990JCP 1990-- 56% of restorations 56% of restorations had overhangs, 32% of pockets had overhangs, 32% of pockets associated with overhangs bled.associated with overhangs bled.

�� JanssonJansson-- JCP 1994JCP 1994-- ““The influence of The influence of a marginal overhang on pocket depth a marginal overhang on pocket depth and attachment loss decreases with and attachment loss decreases with increasing pocket depth.increasing pocket depth.””

Review Article:Review Article:Detection of localized Detection of localized

toothtooth--related factors that related factors that predispose to periodontal predispose to periodontal

infections.infections.Matthews DC, Tabesh M. Periodontol 2000, Matthews DC, Tabesh M. Periodontol 2000,

2004;34:1362004;34:136--150.150.

Local ToothLocal Tooth--related Factorsrelated Factors�� MolarsMolars

�� FurcationsFurcations�� Root trunk lengthRoot trunk length�� Size of furcation entranceSize of furcation entrance�� Bifurcation ridgesBifurcation ridges�� Root concavitiesRoot concavities�� Cervical enamel projectionsCervical enamel projections�� Premolar concavitiesPremolar concavities

Local ToothLocal Tooth--related Factorsrelated Factors�� Overhanging restorationsOverhanging restorations�� Subgingival margins and biologic widthSubgingival margins and biologic width�� Restorative materialsRestorative materials�� ProsthesesProstheses-- TKPs. Increased mobility, TKPs. Increased mobility,

inflammation, and pocketing around abutments.inflammation, and pocketing around abutments.�� CrowdingCrowding�� Vertical root fracturesVertical root fractures�� Mucogingival deformitiesMucogingival deformities�� Adjacent hopeless teeth.Adjacent hopeless teeth.

Systemic Disease Systemic Disease OverviewOverview--

Risk Assessment in Risk Assessment in Clinical PracticeClinical Practice

Ronderos M, Ryder MI. Periodontol Ronderos M, Ryder MI. Periodontol 2000 2004;34:1202000 2004;34:120--135.135.

Risk Assessment in Clinical PracticeRisk Assessment in Clinical PracticeRonderos M, Ryder MI. Periodontol 2000, 2004;34:120Ronderos M, Ryder MI. Periodontol 2000, 2004;34:120--135.135.

�� Behavioral risk factorsBehavioral risk factors�� SmokingSmoking�� ComplianceCompliance

�� Systemic risk factorsSystemic risk factors�� Diabetes and glycemic controlDiabetes and glycemic control�� HIV infectionHIV infection�� OsteoporosisOsteoporosis�� Familial and genetic risk factorsFamilial and genetic risk factors�� Psychological factorsPsychological factors�� AgingAging�� Microbiological risk factorsMicrobiological risk factors

© Francis G. Serio, DMD, MS, MBA

Diabetes and Related Diabetes and Related DisordersDisorders

�� DiabetesDiabetes

�� A metabolic disorder in which the body A metabolic disorder in which the body doesndoesn’’t produce or use insulin properlyt produce or use insulin properly

�� Affects approximately 7% of people in the Affects approximately 7% of people in the United StatesUnited States——almost 21 millionalmost 21 million

�� Sixth leading cause of death among Sixth leading cause of death among Americans Americans

National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 06–3873. Available at: www.diabetes.niddk.nih.gov. Accessed September 26, 2006.Center of Disease Control and Prevention.


Diabetes and Related Diabetes and Related DisordersDisorders


�� Type I diabetesType I diabetes

�� Insulin is not created at allInsulin is not created at all

�� Accounts for about 5% to 10% of diabetes casesAccounts for about 5% to 10% of diabetes cases

�� Requires daily insulin supplementationRequires daily insulin supplementation

�� Type II diabetesType II diabetes

�� Insulin is produced, but used ineffectivelyInsulin is produced, but used ineffectively

�� Accounts for 90% to 95% of diabetes casesAccounts for 90% to 95% of diabetes cases

�� Occurs most often in people who are overweightOccurs most often in people who are overweight

�� May or may notMay or may not require medicationrequire medication

National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 06–3873. Available at: www.diabetes.niddk.nih.gov. Accessed September 26, 2006.

Potential Pathogenic Potential Pathogenic Mechanisms in Mechanisms in Periodontally Periodontally

Related DestructionRelated Destruction

Advanced Advanced Glycation Glycation

Endproducts Endproducts (AGEs)(AGEs)

““Expression of RAGE is enhanced Expression of RAGE is enhanced in diabetics. AGEin diabetics. AGE--EC RAGE EC RAGE interaction results in a shift to interaction results in a shift to favor clot formation, increased favor clot formation, increased monolayer permeability, and monolayer permeability, and

enhanced expression of VCAMenhanced expression of VCAM--1 1 and ILand IL--6. Also see increases in IL6. Also see increases in IL--1, 1,

ILIL--8, and TNF8, and TNF--a.a.”” E. LallaE. Lalla

6 Complications of Diabetes6 Complications of Diabetes

�� Cardiovascular diseaseCardiovascular disease

�� Kidney diseaseKidney disease

�� Eye complicationsEye complications

�� NeuropathyNeuropathy

�� Foot and skin complicationsFoot and skin complications

�� Periodontal diseasePeriodontal disease-- LoeLoe-- 19931993

Periodontal Disease with Poor Periodontal Disease with Poor Diabetic ControlDiabetic Control

�� Genco GroupGenco Group-- Pima Indians which have Pima Indians which have the highest incidence of Type 2 diabetes, the highest incidence of Type 2 diabetes, >50% of adults. Found that poorly>50% of adults. Found that poorly--controlled diabetics had significantly controlled diabetics had significantly more attachment loss and bone loss than more attachment loss and bone loss than wellwell--controlled diabetics or noncontrolled diabetics or non--diabetic diabetic controls. Smoking also contributed. Also controls. Smoking also contributed. Also found that treatment of perio disease may found that treatment of perio disease may affect metabolic control.affect metabolic control.

DiabetesDiabetesGustke CJ. Treatment of periodontitis in the diabetic patient. Gustke CJ. Treatment of periodontitis in the diabetic patient.

A critical review. JCP 1999;26:133A critical review. JCP 1999;26:133--137.137.

�� Both Type 1 and Type 2 diabetes mellitus Both Type 1 and Type 2 diabetes mellitus are associated with increased periodontal are associated with increased periodontal disease susceptibility. Conventional disease susceptibility. Conventional therapy appears to be effective in therapy appears to be effective in diabetics. It has not been demonstrated diabetics. It has not been demonstrated that chemotherapeutics are necessary for that chemotherapeutics are necessary for successful treatment in most diabetic successful treatment in most diabetic patients. The effect of periodontal therapy patients. The effect of periodontal therapy may not be clinically significant.may not be clinically significant.

Improvement in Glycemic Improvement in Glycemic Control with Periodontal Control with Periodontal

TreatmentTreatment�� Grossi, et al.Grossi, et al.-- JP, 1997. Found significant JP, 1997. Found significant

reductions in glycosylated hemoglobin in all reductions in glycosylated hemoglobin in all groups receiving antibiotics as part of groups receiving antibiotics as part of periodontal therapy.periodontal therapy.

�� Kiran M, et al. JCP, 2005. Initial therapy Kiran M, et al. JCP, 2005. Initial therapy significantly decreased HbA1c levels in significantly decreased HbA1c levels in patients with periodontal disease.patients with periodontal disease.

Jansson HJansson H, , Lindholm ELindholm E, , Lindh CLindh C, , Groop LGroop L, , Bratthall GBratthall G. . Type 2 diabetes and risk for Type 2 diabetes and risk for

periodontal disease: a role for dental health periodontal disease: a role for dental health awareness. JCP 2006;33:408awareness. JCP 2006;33:408--414.414.

The best predictor for severe periodontal disease The best predictor for severe periodontal disease in subjects with T2D is smoking followed by in subjects with T2D is smoking followed by HbA1c levels. T2D subjects should be informed HbA1c levels. T2D subjects should be informed about the increased risk for periodontal disease about the increased risk for periodontal disease when suffering from T2D.when suffering from T2D.


Metabolic Properties of FatMetabolic Properties of Fat

�� Increases levels of CIncreases levels of C--reactive protein (CRP), reactive protein (CRP), a key inflammatory marker.a key inflammatory marker.

�� Produces cytokines such as TNFProduces cytokines such as TNF--aa, Il, Il--6, and 6, and others.others.

�� Has resident macrophages that proliferate Has resident macrophages that proliferate as fat increases.as fat increases.

Obesity and InflammationObesity and Inflammation

�� TNFTNF--aa�� IlIl--66

�� Plasminogen activator inhibitorPlasminogen activator inhibitor--11

�� Angiotensinogen Angiotensinogen

�� Vascular endothelial growth factorVascular endothelial growth factor

�� CC--reactive peptidereactive peptide

ObesityObesity-- now a now a major risk factor for major risk factor for periodontal diseaseperiodontal disease


Health Complications of ObesityHealth Complications of Obesity

�� HypertensionHypertension�� DiabetesDiabetes�� Abnormal blood fatsAbnormal blood fats�� StrokeStroke�� OsteoarthritisOsteoarthritis�� Sleep apneaSleep apnea�� Cancer Cancer �� Gallstones Gallstones �� Gout Gout


Health Complications of DiabetesHealth Complications of Diabetes


�� Poor wound healing Poor wound healing

�� Altered inflammatory responseAltered inflammatory response

�� RetinopathyRetinopathy

�� NeuropathyNeuropathy

�� NephropathyNephropathy

�� Periodontal diseasePeriodontal disease

An Update on HIV An Update on HIV and Periodontal and Periodontal

DiseaseDiseaseRyder MI. J Periodontol 2002;73:1071Ryder MI. J Periodontol 2002;73:1071--

1078.1078.

HIV UpdateHIV UpdateRyder MI. J Periodontol 2002;73:1071Ryder MI. J Periodontol 2002;73:1071--1078.1078.

�� HAART therapyHAART therapy-- highly active antiretroviral highly active antiretroviral therapiestherapies-- reverse transcriptase inhibitors and reverse transcriptase inhibitors and protease inhibitorsprotease inhibitors-- viral loads may decrease to viral loads may decrease to undetectable levels.undetectable levels.

�� With HAART, atypical HIVWith HAART, atypical HIV--associated oral lesions associated oral lesions have decreased by 30%.have decreased by 30%.

�� Necrotizing disease suggests low CD4 counts.Necrotizing disease suggests low CD4 counts.

�� HIV patients have more AL than healthy patients.HIV patients have more AL than healthy patients.

�� Periodontal treatment has not changed in 15 years.Periodontal treatment has not changed in 15 years.

Periodontitis Modified by Periodontitis Modified by Systemic FactorsSystemic Factors-- HIV InfectionHIV Infection�� HIVHIV--infected individuals may exhibit the infected individuals may exhibit the

following:following:

��Linear gingival erythemaLinear gingival erythema

��Necrotizing ulcerative gingivitis/ Necrotizing ulcerative gingivitis/ periodontitisperiodontitis

��Severe localized periodontitisSevere localized periodontitis

��Severe destructive necrotizing stomatitis Severe destructive necrotizing stomatitis affecting gingiva and boneaffecting gingiva and bone

San Giacomo, et al. OOOO, 1990; Williams, et al. OOOO, San Giacomo, et al. OOOO, 1990; Williams, et al. OOOO, 1990; Winkler, et al. 1996; Winkler, et al. JADA, 1989.1990; Winkler, et al. 1996; Winkler, et al. JADA, 1989.

Influence of sex Influence of sex hormones on the hormones on the

periodontiumperiodontiumMascarenhas P, Gapski R, AlMascarenhas P, Gapski R, Al--Shammari K, Wang Shammari K, Wang

HH--L. J Clin Periodontol 2003;30:671L. J Clin Periodontol 2003;30:671--681.681.

Hormonal InfluencesHormonal InfluencesMealey BL, Moritz AJ. Periodontol 2000 2003;32:59Mealey BL, Moritz AJ. Periodontol 2000 2003;32:59--81.81.

�� Primarily estrogens and progestins affect Primarily estrogens and progestins affect gingival tissues.gingival tissues.

�� See selective overgrowth of See selective overgrowth of P. intermediaP. intermediaby substituting estradiol and progesterone by substituting estradiol and progesterone for menadione.for menadione.

�� Pregnancy gingivitis in 30Pregnancy gingivitis in 30--100% of 100% of pregnant females and 10% develop pregnant females and 10% develop pyogenic granulomas.pyogenic granulomas.

HormoneHormone--Related Periodontal Related Periodontal DiseaseDisease

�� Sooriyamoorthy and Gower. JCP 1989;16:201Sooriyamoorthy and Gower. JCP 1989;16:201--208.208. A good review. High counts of A good review. High counts of B. B. intermedius intermedius ((P. intermediaP. intermedia) have been observed ) have been observed in users of oral contraceptives and in the 2in users of oral contraceptives and in the 2ndnd

trimester. This is due to the competitive trimester. This is due to the competitive binding of progesterone and naphthaquinone, binding of progesterone and naphthaquinone, an essential nutrient for bacterial growth. See an essential nutrient for bacterial growth. See increased increased P. intermediaP. intermedia counts and counts and pseudopockets, rather than attachment loss.pseudopockets, rather than attachment loss.

Boyapati L, Wang HBoyapati L, Wang H--L. The L. The role of stress in periodontal role of stress in periodontal disease and wound healing. disease and wound healing.

Periodontol 2000, 2007;44:195Periodontol 2000, 2007;44:195--210.210.

““There is a plausible There is a plausible pathophysiological pathophysiological

basisbasis…….stress is associated .stress is associated with more severe periodontal with more severe periodontal

disease.disease.”” Has not been Has not been definitively proven. Biologic definitively proven. Biologic

plausibility is the support.plausibility is the support.

Review ArticleReview ArticleDongariDongari--Bagtzoglou A. Drug associated gingival Bagtzoglou A. Drug associated gingival

enlargement. An AAP Information Paper. JP enlargement. An AAP Information Paper. JP 2004;75:14242004;75:1424--1431.1431.

�� A MUST READ!A MUST READ!

�� Over 20 drugs cause enlargement.Over 20 drugs cause enlargement.

�� Prevalence info difficult to getPrevalence info difficult to get-- current thinkingcurrent thinking-- phenytoin phenytoin 50%, nifedipine 650%, nifedipine 6--15%, CsA 2515%, CsA 25--30%.30%.

�� Enlargement of CT, collagen and ground substance. More Enlargement of CT, collagen and ground substance. More fibroblasts controversial.fibroblasts controversial.

�� Mechanism poorly understood.Mechanism poorly understood.

�� Fibroblasts react to ILFibroblasts react to IL--11BB. .

�� Recurrence rate of overgrowth about 40%.Recurrence rate of overgrowth about 40%.

MedicationsMedications

�� PhenytoinPhenytoin�� Nifedipine, other calcium channel Nifedipine, other calcium channel

blockersblockers�� Cyclosporin ACyclosporin A�� TacrolimusTacrolimus-- (Prograf(Prograf®®))-- 14% of subjects 14% of subjects

may have gingival overgrowth. may have gingival overgrowth. (Sekiguchi, et al. 2007)(Sekiguchi, et al. 2007)

Periodontitis Modified by Systemic Periodontitis Modified by Systemic FactorsFactors

MedicationsMedications-- AntiAnti--seizure drugsseizure drugsKinane D. Ann Periodontol 1999;4:54Kinane D. Ann Periodontol 1999;4:54--63.63.

�� Some degree of gingival enlargement in 36Some degree of gingival enlargement in 36--67% 67% of patientsof patients-- Klar, JPHD, 1973.Klar, JPHD, 1973. May be higher in May be higher in institutionalized patientsinstitutionalized patients-- Hassel, et al. JCP, Hassel, et al. JCP, 1984.1984.

�� Labial gingiva more severely affected. Labial gingiva more severely affected. Thorstensson, Swed Dent J, 1995.Thorstensson, Swed Dent J, 1995.

�� Valproic acid and vigabatrin may also cause Valproic acid and vigabatrin may also cause gingival overgrowth. gingival overgrowth. Katz, et al. JCP, 1997Katz, et al. JCP, 1997..

MedicationsMedications-- Cyclosporin ACyclosporin A

�� Acts solely on cellActs solely on cell--mediated immunitymediated immunity

�� Resembles phenytoin overgrowth clinically and Resembles phenytoin overgrowth clinically and histopathologically, is seen in 30% of recipients, histopathologically, is seen in 30% of recipients, related to serum concentration of drugrelated to serum concentration of drug--Seymour, et al. JCP, 1987.Seymour, et al. JCP, 1987.

�� Combination of nifedipine and cyclosporin Combination of nifedipine and cyclosporin shows greater overgrowth than cyclosporin shows greater overgrowth than cyclosporin alonealone-- Ellis, et al. JCP, 1999.Ellis, et al. JCP, 1999.

Calcium Channel Blockers and Calcium Channel Blockers and Gingival OvergrowthGingival Overgrowth

�� DihydropyridinesDihydropyridines

�� Nifedipine (AdalatNifedipine (Adalat®®, Procardia, Procardia®®))-- 1010--15%15%--often reversible with d/c of drug. Almost often reversible with d/c of drug. Almost 80% of all CCB overgrowth reported cases.80% of all CCB overgrowth reported cases.

�� Others (amlodipineOthers (amlodipine-- NorvascNorvasc®®))-- yesyes

�� OthersOthers-- rare overgrowthrare overgrowth

�� Diltiazem (CardizemDiltiazem (Cardizem®®))

�� Verapamil (CalanVerapamil (Calan®®))

�� Bepridil (VascorBepridil (Vascor®®))

MedicationsMedications-- MembraneMembrane--ion ion channel blockerschannel blockers

�� CalciumCalcium--channel blockerschannel blockers-- influence influence fibroblasts to overproduce collagen matrix fibroblasts to overproduce collagen matrix and ground substance when stimulated by and ground substance when stimulated by gingival inflammationgingival inflammation-- Ellis, JP, 1999.Ellis, JP, 1999.

�� No link with periodontitisNo link with periodontitis

�� Similar to phenytoin overgrowthSimilar to phenytoin overgrowth-- Bullon, et Bullon, et al. OOOO, 1995.al. OOOO, 1995.

Genetics TerminologyGenetics Terminology�� HeritabilityHeritability-- the proportion of phenotypic variation the proportion of phenotypic variation

within pairs attributed to genetic variation. A within pairs attributed to genetic variation. A heritability estimate of 50% means that one half of heritability estimate of 50% means that one half of the variance in the population is attributable to the variance in the population is attributable to genetic variance. It does not mean that 50% of genetic variance. It does not mean that 50% of offspring of affected parents will be affected. Need offspring of affected parents will be affected. Need large samples of reared together twins to estimate large samples of reared together twins to estimate heritability accurately. Heritability estimates for heritability accurately. Heritability estimates for MZ twins is about 50%.MZ twins is about 50%.

Genetic ApproachesGenetic Approaches

�� MichalowiczMichalowicz-- JP, 2000JP, 2000-- Looked at MZ Looked at MZ and DZ twins. Calculated that adult and DZ twins. Calculated that adult periodontitis had a 50% heritability (half periodontitis had a 50% heritability (half of the variance in disease in the of the variance in disease in the population is attributed to genetic population is attributed to genetic variance)variance)

Kinane DFKinane DF, , Shiba HShiba H, , Hart TCHart TC. The . The genetic basis of periodontitis. P2000 genetic basis of periodontitis. P2000

2005;39:912005;39:91--117.117.

Among other things, debunks the utility of ILAmong other things, debunks the utility of IL--1 1 testing. Useful in only 30% of Europeans, testing. Useful in only 30% of Europeans, 2.3% of Chinese, and low in African2.3% of Chinese, and low in African--American American populations. Very good review.populations. Very good review.

Stabholz A, Soskolne WA, Shapira Stabholz A, Soskolne WA, Shapira L. Genetic and environmental risk L. Genetic and environmental risk

factors for chronic periodontitis factors for chronic periodontitis and aggressive periodontitis. and aggressive periodontitis.

Periodontology 2000, 2010;53:138Periodontology 2000, 2010;53:138--153. 153.

The Immunology of The Immunology of Aggressive Aggressive

PeriodontitisPeriodontitis

Hypoimmune Hypoimmune or or

Hyperimmune???Hyperimmune???

Tobacco Use and Tobacco Use and Periodontal DiseasePeriodontal Disease

Smoking and Periodontal Smoking and Periodontal DiseaseDisease

�� Bergstrom, Preber GroupBergstrom, Preber Group-- Several studies in Several studies in JCP from 1987JCP from 1987--2005.2005. With other factors With other factors controlled for, found smokers had more bone controlled for, found smokers had more bone loss than nonsmokers. One study was done in a loss than nonsmokers. One study was done in a group of dental hygienists with a high degree of group of dental hygienists with a high degree of oral hygiene. Also found that smoking affected oral hygiene. Also found that smoking affected therapy, causing less probe depth decrease. therapy, causing less probe depth decrease. This was more evident after scaling the This was more evident after scaling the maxillary anterior segment. Rate of bone loss maxillary anterior segment. Rate of bone loss slows once a patient stops smoking. More slows once a patient stops smoking. More calculus found in smokerscalculus found in smokers-- dose dependent.dose dependent.

Evidence for Smoking as an Etiologic Evidence for Smoking as an Etiologic Factor in PeriodontitisFactor in PeriodontitisCriteria for CausationCriteria for Causation

Johnson GK, Hill M. J Periodontol 2004;75:196Johnson GK, Hill M. J Periodontol 2004;75:196--209.209.

�� Strength of associationStrength of association-- crosscross--sectional and casesectional and case--controlled studies demonstrate a moderate to controlled studies demonstrate a moderate to strong association between smoking and strong association between smoking and periodontitisperiodontitis

�� ConsistencyConsistency-- multiple studies of various designs multiple studies of various designs have demonstrated this associationhave demonstrated this association

�� SpecificitySpecificity-- disease progression slows in patients disease progression slows in patients who stop smoking compared to those who who stop smoking compared to those who continue to smokecontinue to smoke



�� TemporalityTemporality-- Longitudinal studies show that Longitudinal studies show that smokers do not respond as well to periodontal smokers do not respond as well to periodontal therapy as nontherapy as non--smokerssmokers

�� Biologic gradientBiologic gradient-- there is a dosethere is a dose--response effect response effect in that heavy smokers have increased disease in that heavy smokers have increased disease severity compared to light smokersseverity compared to light smokers

�� Biologic plausibilityBiologic plausibility-- supported by tobaccosupported by tobacco’’s s negative effects on microbial and host response negative effects on microbial and host response parametersparameters



�� CoherenceCoherence-- the effects of smoking on periodontitis the effects of smoking on periodontitis are consistent with our knowledge of the natural are consistent with our knowledge of the natural history of periodontal diseasehistory of periodontal disease

�� AnalogyAnalogy-- periodontal effects of smoking are periodontal effects of smoking are analogous to other adverse smokinganalogous to other adverse smoking--related related general health effectsgeneral health effects

�� ExperimentExperiment-- evidence not currently availableevidence not currently available

Overlap leads to an Overlap leads to an increasing increasing

susceptibility to susceptibility to periodontitis.periodontitis.

Genco GroupGenco Group5 Major Factors5 Major Factors

�� AgeAge�� SmokingSmoking**�� Uncontrolled diabetesUncontrolled diabetes**�� Bacteroides forsythus (Tannerella Bacteroides forsythus (Tannerella

forsythia)forsythia)�� Porphyromonas gingivalisPorphyromonas gingivalis**The double whammy!!!**The double whammy!!!

Periodontitis as a Periodontitis as a Risk Factor for Risk Factor for

Systemic DiseaseSystemic Disease

Medical Conditions Related to Medical Conditions Related to Periodontal DiseasePeriodontal Disease


�� PrePre--term low birth weight infantsterm low birth weight infants

�� Rheumatoid arthritisRheumatoid arthritis


�� Pneumonia Pneumonia

Is it causality, Is it causality, contributory,contributory,

or coincidence???or coincidence???

Criteria to Accept a Causal Criteria to Accept a Causal RelationshipRelationship

�� Biological plausibilityBiological plausibility

�� Consistency of associationsConsistency of associations

�� Strength of the associationStrength of the association

�� Temporal consistencyTemporal consistency

�� Specificity of the associationSpecificity of the association

Criteria to Accept a Causal Criteria to Accept a Causal RelationshipRelationship

�� Consistency of the findingsConsistency of the findings

�� DoseDose--response effectresponse effect

�� Support from experimental evidenceSupport from experimental evidence

Calculating Calculating Odds RatiosOdds Ratios

For example: If the incidence For example: If the incidence of oral cancer in a smoking of oral cancer in a smoking population is 0.002 and in a population is 0.002 and in a nonsmoking population is nonsmoking population is 0.0004, the odds ratio is 0.0004, the odds ratio is

0.002/0.0004 = 50.002/0.0004 = 5

Odds ratio >1 indicates a Odds ratio >1 indicates a positive association, <1 a positive association, <1 a

negative association, negative association, and =1 no association.and =1 no association.

When is an odds When is an odds ratio meaningful?ratio meaningful?

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