Risk Factors

Associated with

Periodontal Disease

Dr. Samjhana Kashaju Joshi

Periodontitis is an inflammatory condition

initiated by microbial plaque

influenced by an array of factors that affect the development and progression of the disease.

The development and course of periodontitis

depends upon

specific inherited, behavioral or environment conditions ---so called risk factors.

Risk factor --- can be modified Risk determinant---cannot be modified

Risk factors

Smoking Diabetes Stress Drugs Systemic disease Nutrition

Risk determinants

•Genetics•Socioeconomic status•Gender

Smoking

Major risk factor

Can be attributed to current or former smoking

Severity is directly related to both –the number of cigarettes smoked per day- the numbers of years a patient has smoked

Clinically---Smokers exhibit reduced gingival bleeding and inflammation---greater levels of periodontal pocketing in anterior maxillary segment

Impairment of local neutrophil function by tobacco smoke and its components

Affect the healing ability

Diabetes

Type 1 diabetes ( IDDM)

Type 2 diabetes ( NIDDM)

Factors contributing are---

The degree of diabetic control The age of onset The duration of the disease

Complex mechanism

a) Dysregulation of polymorph function b) Altered collagen metabolism c) Microvascular damage

“Share similar pathogenic mechanisms with diabetic foot ulcers”

Bi-directional relationship -- Diabetes and Periodontal disease

“Successful treatment and maintenance of periodontal health in diabetic patients should be a major goal, to improve

both the oral and general health of the patient”

Stress

Has impact on the normal functioning of the immune system

--Negative life events --Unemployment --Social strain

Mechanism

Specific periodontal pathogens can utilize stress hormones to stimulate growth and expression of virulence factors

providing another potential mechanism linking stress levels with periodontitis

Drugs

Anticonvulsant– Phenytion Immunosuppressant– Cyclosporin Calcium channel–blocking drugs as Nifedipine, Amlodipine

Induces gingival overgrowth classically begins in the inter-dental papillae

Complex interaction between

the drugs, host fibroblasts and inflammatory cells

resulting in an increased deposition of connective tissue

supporting a hyperproliferative epithelium

Difficulty in plaque control adds oedematous inflammatory

component to the overgrowth

Management should begin by change in medication in consultation with the patient’s physician.

Mechanical cleaning and meticulous plaque control.

Surgical removal of residual redundant tissue may also be required.

Systemic Disease

Tissue destruction associated with periodontitis results from the

host response to bacterial insult.

Bystander Damage---periodontal pathogens and the immune

response

Systemic conditions affect the host defense mechanism

--positive impact on disease progression

Systemic conditions and periodontitis

Nutrition

Potential role of diet and nutrition

Severe Vitamin C deficiency---Scorbutic gingivitis

Ulcerative gingivitis, gingival hemorrhage, rapid periodontal pocket formation, tooth loss

Vitamin- C – an important antioxidant

Role in the inhibition of reactive oxygen species (ROS)

tissue damage in periodontal disease

Genetic Factors

Major role in determining disease severity

Caused by gene polymorphisms, IL-1 acting as a contributory risk factor

IL-1 activates the inflammatory and immune responses to bacterial virulence factors stimulates the release of host proteolytic enzymes and osteoclastic activation --- results in periodontal tissue breakdown

Genetic conditions and periodontal diseases

Socioeconomic status

Complex, multi-faceted parameter

Higher socioeconomic status-

better plaque control and increased dental visits

decreased prevalence of periodontal disease

Gender

Higher in males

Related to poorer plaque control and lower dental attendance rates in males

Tooth-related factors

Increased risk due to an increased risk of plaque retention--- inaccessibility to cleaning.

Occlusal forces—Class II div 2 malocclusions, loss of posterior support.

Affects both the healthy periodontium and the affected teeth with existing periodontal disease.

Removal of --Occlusal interferences in both centric occlusion and lateral excursive movements

Local risk factors for periodontal disease

Microbial factors

Over 500 bacteria have

been identified

Authors categorized

bacterial species into

colour coded groups

based on their

pathogenecity:

Lets take “History” of every patient very carefully keeping all these probable risk factors in our mind!!!

Lets always think of “Risk Assessment”

Complexity 1 BPE Score 1 – 3 in any sextant

Complexity 2 BPE Score of 4 in any sextant Surgery involving the periodontal tissuesComplexity 3 Surgical procedures associated with osseointegrated implants. Surgical procedures involving periodontal tissue augmentation

and/or bone removal (e.g. crown lengthening surgery).

PERIODONTAL TREATMENT ASSESSMENT

Based upon the Basic Periodontal Examination (BPE) Criteria:

BPE score of 4 in any sextant and including one or more of the following:

Patient’s age under 35 years.

Smoking 10+ cigarettes daily.

A concurrent medical factor that is directly affecting the periodontal tissues.

Root morphology that adversely affects prognosis.

Rapid periodontal breakdown >2 mm attachment loss in any one year.

Complexity 1 cases may be treated in general practice,

Complexity 2 cases either referred or treated by the GDP and

Complexity 3 cases mostly referred.