Periodontal Diseases: Risk Factors & Prognosis

• This module reviews risk factors for periodontal diseases and establishing a prognosis post-diagnosis.
• Knowledge of risks and prognostication aids in assessment, prevention, and treatment.

Risk Assessment and Prognosis

• Risk assessment identifies predisposing elements or influences on existing periodontal disease.
• Prognosis is a prediction of disease course, duration, and outcome, based on pathogenesis knowledge and risk factors.

Risk Factors

• Risk factors are environmental, behavioral, or biologic factors increasing disease likelihood.
• Tobacco smoking directly relates to periodontal disease prevalence and negatively impacts therapy response.
• Diabetes mellitus patients experience higher prevalence and severity of periodontal disease; severe periodontal disease is a risk factor for poor glycemic control.
• Effective periodontal therapy may positively affect diabetes control.
• Pathogenic bacteria and microbial tooth deposits are risk factors.
• Plaque biofilm composition and quality are important, not just quantity. Three bacteria identified as etiologic agents are: Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Bacteroides forsythus.

Anatomic Factors

• Anatomic factors like furcations, root concavities, developmental grooves, cervical enamel projections, enamel pearls, and bifurcation ridges predispose individuals to periodontitis by harboring bacterial plaque.
• Multi-rooted teeth are at higher risk for attachment loss in furcation regions.
• Anatomic furca begins ~5mm from the CEJ and opening is difficult to detect clinically.
• Standard instruments may not effectively disrupt plaque biofilm in furcation regions, even in early lesions.
• Maxillary first premolars often have mesial root concavities inaccessible to oral hygiene/instrumentation, and the mesial concavity may resemble anatomic furcation.
• Lingual surfaces of maxillary lateral incisors may feature grooves that progress along the root, potentially leading to subgingival plaque biofilm progression.

Root Proximity Complications

• Molars with divergent root morphology may position roots closely to adjacent teeth.
• The interproximal bone may be thin, increasing susceptibility to inflammatory resorption.
• Maxillary first and second molars are common sites for root proximity complications

Restorative Factors

• Subgingival margins, frequently placed to access caries or for esthetics, are rougher than adjacent tooth surfaces and facilitate plaque biofilm accumulation
• Subgingival restorations contribute to increased subgingival periopathogenic plaque deposits and can impinge on biologic width.
• Biologic width refers to the dimensions of epithelial and connective tissue attachment.
• Dental restorations should not hinder connective tissue attachment to the alveolar bone.
• Violating biologic width initiates chronic inflammation and attachment/bone loss to reestablish dimensions.
• Overcontoured restorations contribute to increased plaque biofilm deposits along gingival margins and may narrow embrasures, limiting access for oral hygiene.

Risk Determinants

• Risk determinants are non-modifiable risk factors.
• Genetic factors are a risk determinant.
• Age is a risk determinant.
• Gender determines the risk; males are more prone to periodontitis.
• Socioeconomic status a risk determinant.
• Lower socioeconomic status correlates with poor oral health due to decreased awareness and dental visits.
• Emotional stress interferes with immune function and increases the incidence of ANUG during stressful periods.

Risk Indicators

• Risk indicators are probable or putative risk factors identified in cross-sectional studies but not confirmed through longitudinal studies.
• HIV/acquired immune deficiency syndrome is a risk indicator.
• Osteoporosis is a risk indicator.
• Infrequent dental visits are a risk indicator.

Risk Markers

• Risk markers/predictors are associated with increased disease risk but do not cause the disease.
• A previous history of periodontal disease is a risk marker
• Bleeding on probing, along with increased pocket depth, may predict future attachment loss.

Prognosis

• Prognosis is established after diagnosis and before treatment planning. Risk factors and prognosis are interrelated.
• Prognosis worsens with the presence of risk factors in patients diagnosed with periodontal disease.
• Descriptors of prognosis includes excellent, good, fair, poor, questionable, and hopeless.
• Excellent prognosis: no bone loss, excellent condition, good patient cooperation, no systemic or environmental factors.
• Good prognosis: adequate bone support, possibilities to control etiologic factors, maintainable dentition, adequate patient cooperation, systemic/environmental factors controlled.
• Fair prognosis: less than adequate bone support, some mobility, grade 1 furcation, adequate maintenance possible, acceptable cooperation, limited systemic/environmental factors.
• Poor prognosis: moderate to advanced bone loss, tooth mobility, grade I/II furcation, difficult to maintain areas, doubtful cooperation, systemic/environmental factors.
• Questionable prognosis: advanced bone loss, grade II/III furcation, inaccessible areas, systemic/environmental factors.
• Hopeless prognosis: advanced bone loss, non-maintainable areas, extractions indicated, uncontrolled systemic/environmental factors.

Prognosis Aspects

• Overall prognosis concerns the entire dentition and determines the extent of treatment.
• Factors to consider for overall prognosis: clinical and systemic/environmental factors.
• Clinical factors: patient age, disease severity, plaque control, and patient compliance.
• Systemic/environmental factors: smoking, systemic diseases/conditions, genetic factors, and stress.
• Individual prognosis accounts for the prognosis of each tooth. Mobility is studied.
• Considerations include teeth adjacent to edentulous areas, remaining bone location relative to individual root surfaces, relation to adjacent teeth, attachment level, infrabony pockets, furcation involvement, caries, non-vital teeth, root resorption, and developmental defects.

Prognosis for Certain Patients

• For plaque-induced gingival diseases, the prognosis includes dental plaque only.
• Gingivitis associated with dental plaque only has a good prognosis with removal of local irritants and patient cooperation.
• Prognosis for plaque-induced gingival diseases modified by systemic factors depends on controlling plaque and systemic conditions.
• Prognosis for plaque-induced gingival diseases modified by medications relies on alternative medication treatment.
• Gingival diseases modified by malnutrition: prognosis depends on deficiency severity/duration and reversing the deficiency via dietary supplementation.
• Non-plaque-induced gingival lesions: prognosis depends on eliminating the infection or causative agent.
• For chronic periodontitis, is slight to moderate.
• When inflammation is controlled through oral hygiene and plaque removal, the prognosis is good.
• Severe, non-compliant chronic periodontitis patients may receive a downgraded prognosis.
• Aggressive periodontitis' prognosis is poor, especially in generalized cases.
• Periodontitis as a manifestation of systemic diseases: prognosis is fair to poor.
• Necrotizing ulcerative periodontitis prognosis: fair to poor.
• The Module is about treatment planning and the rationale for periodontal Therapy.
• It presents the different phases in treatment planning, and what treatment is needed for each case.
• It is vital to understand how to rationalize the need for periodontal treatment.
• Treatment for every stage is discussed.

Treatment Planning & Rationale

• After diagnosis and prognosis, a treatment plan is made, the blueprint for case management.
• A periodontal treatment plan aims to create a well-functioning dentition in a healthy periodontal environment.

Treatment Plan Characteristics

• It outlines treatment procedures in a systematic sequence.
• A good plan of treatment is well thought out, advanced, and all-encompassing.
• The aim is to reach both short-term and long-term goals.
• Short-term goals eliminate gingival inflammation and correct its causes.
• Long-term goals require reconstruction of a healthy dentition fulfilling all functional and aesthetic requirements.
• The treatment plan should be guided with need for emergency treatment acute condition.
• The following is assessed during the process: teeth to be retained or extracted, necessary pocket therapy techniques, need for occlusal correction, use of implant therapy, temporary and final restorations, need for orthodontic consultation, endodontic therapy, aesthetic considerations, and overall therapy sequence.

Sequence of Treatment

• Treat emergencies like dental/periapical or periodontal abscesses and extract hopeless teeth, providing interim dentures.
• Phase I therapy, non-surgical phase, involves plaque control, patient education, diet control in rampant caries, calculus/root planing, correcting irritating restorative factors, caries excavation, antimicrobial therapy, occlusal therapy, minor orthodontic movement and providing provisional splints or prosthesis.
• An evaluation of response to Phase I is then needed.
• Rechecking for pocket depth, gingival inflammation, plaque, and calculus must be done as check
• Phase II (Surgical Phase:) will be performed during pocket periodontal therapy with placements of implants, and endodontic therapy.
• Finalizing the restorations and appliance and evaluation is done on Phase III (Restorative Phase).
• Phase IV therapy, which is the maintenance phase, requires consistent rechecking for plaque, calculus, gingival concerns, occlusion and mobility, and pathological changes.

Explaining Treatment

• When explaining treatment plans to patients, be specific and positive.
• It's best to present treatment as a unit.

Importance of Treatment

• Periodontal disease is a microbial infection and a risk factor for life-threatening diseases.
• Eliminating periodontal infection is essential for prosthetic restorations' feasibility and to avoid damage to teeth.

Rationale

• Periodontal therapy objectives include eliminating pain; gingival inflammation, bleeding, and infection; reducing periodontal pockets and tooth mobility; ceasing pus formation; arresting soft tissue/bone destruction; establishing optimal occlusal function/physiologic gingival contour; restoring tissues/preventing recurrence/reducing tooth loss.

Types of Healing

• Regeneration is a natural renewal via new cells/substances forming new tissues, elusive for periodontal reconstruction.
• Repair—restores tissue continuity at the same root level base, healing via scar/epithelial adaptation.
• Final periodontal pocket healing depends on healing stages.
• Epithelial adaptation is where there is close gingival epithelium apposition to tooth surface but with no gain in gingival fiber height.
• New attachment is the embedding of new periodontal ligament fibers into new cementum and attachment

Healing

• Excessive tissue manipulation and trauma delays healing.
• Systemic factors delaying healing include age, diseases, malnutrition, hormones, and stress.
• Phase I Therapy is often referred to as the nonsurgical phase.
• First phase is very important and can not be overemphasized
• It is known as the etiotropic phase.
• Etiotropic refers to the fact that this treatment aims to be directy against the agent or cause of the disease.
• This set of procedures may consist of the only treatment needed to solve the patient's periodontal problems, or they may constitute the preparatory phase for surgical therapy

Rational Removal

• Aims for the reduction and elimination of causative and contributing factors that includes effective plaque control through complete calculus removal, correcting of restorations and prosthesis, restoration of carious lesions, Orthodontic tooth movement, treatment of occlusal trauma, and removal of hopeless teeth.
• An amount of appointments are needed to complete, the factors are general health, number of teeth present, severity of tartar, pocket depth, furcation, tooth alingment, margins of restoration and access to the location.

Sequence and Procedures

• Sequence of procedures involves; Limited Plaque Control Instruction, Supragingival removal of calculus, recontouring, obturation, comprehensive steps, sub gingival removal and final tissue reevaluation.
• Plaque causes major issues when paired with calculus.
• The steps mentioned are implemented to remove the agents and maintain stability within the mouth.
• Plaque is one of the etiologies.
• Regular plaque dental is vital.
• Removal was studied in 1965.

Mechanical Methods

• Demonstrate a shift of microflora.
• Gingivititis is reversible with proper steps.
• Control, interdental cleaning, tooth brushing and proper technique are vital.

Chemical Aspects

• Use antimicrobial to deal with areas of concerns in the mouth.
• Professional create conditions.
• Plaque /calcuclus must be removed from the tooth, using root planing and scaling.
• Smooth surfaces are needed to deter the buildup.
• All factors with Iatrogenic must be assessed to avoid further risks.

Subgingival Scaling

• If sub scaling is more is complex.
• Curettage is a debridement of tissue and must be intentional for the procedure.
• Drugs must be classified correctly as mentioned earlier to be used correctly.
• Act on the specific locations, that has better outcome with the correct delivery.
• Superinfections are a disadvantage to medications given.
• Commonly used in conjunction with antibiotic therapy.
• Penicillins can have allergic reactions to some.
• Aug is given to patients for localized locations.
• Metro is used for infections with a proper dosage.
• Tetracycline is derived from strep, and great at fighting the disease.

Phase II

• Provides direct access and visibility during procedures towards the root areas and alveolar bone of the teeth.
• Knowledge of indications and surgical processes will decide the most appropriate choice selected for future treatments.
• Purpose is for Control and correction of diseases.
• This may mean correcting or eliminating disease and placement of implants.

Periodontal Zone

• P1; soft tissue around pocket.
• P2; tooth surface (roughness)
• P3; irregularities in bone and bone presence.

Pocket Therapy

• Removing the tooth with surgery, but will save.
• Removing irritants.
• Indication for irregular bone.
• Grade 2 and 3 furcations.

Method Selection

• Methods differ based on characteristics.
• Access to instrumentation.
• Response and all those listed before previously.

Ginival and perio

• Must be conservative approach.
• Treatments with flaps may be required
• Must consider every factor before approaching a case.
• Reshaping comes from the correct use
• Follow function.
• Pocket side by side and angles must be addressed according to every factor.
• The new attachment must exist.
• Local procedures and factors are used daily.
• Regeneration.

Outcome

• The objective is to ensure, results and tissue with cells will result.
• Methods have new goals now with new ways to combat periodontal issues.
• Attachment is best with this route with results.
• Removal of is used a barrier can used.

Guided Technique

• Uses better cells. .