Dental Public Health Al Azhar University Gaza Lama k El Banna

2. College of Dentistry
Dental Public Health
Prevention of Periodontal Disease
Prevention of Occlusal Abnormalities
Dr. Hazem El Ajrami
Master Degree in Orthodontic & Pedodontic

3. •Periodontal disease is the affection of the
periodontium or the supporting tissues of the teeth.
•It may range in the same mouth from mild
inflammation of the gingival margin (marginal
gingivitis) to a severe destruction of the periodontal
ligaments and the supporting alveolar bone.
•Epidemiological surveys and clinical studies
demonstrate a direct association between the
prevalence and severity of periodontal diseases and
the accumulation of bacterial plaque and debris.
• Personal care results in the resolution of the
inflammation and slowing in the rate of loss of tooth
support.

5. •Normal gingiva has been defined as pink, firm,
stippled, with well-formed papillae and gingival
sulci (crevices) shallow in depth and without
exudate.
• Three areas are distinguished clinically in the
gingiva, namely the interdental papilla, the
gingival margin which forms the soft tissue wall
of the gingival crevice, and the attached gingiva
which is firmly bound down to the underlying
cementum and alveolar bone.

8. •The initiating factor leading to periodontal disease
is the bacterial component of the plaque around the
teeth or overlying the calculus on the teeth.
•The prevention of plaque accumulation or its
regular removal is the best method of avoiding
periodontal disease, and therefore the most
important preventive measure is the effective use of
the toothbrush and other devices when necessary.
• Today, only the mechanical action of the brush has
been regularly shown to remove the bacterial and
other soft deposits.

10. •There is sufficient evidence from controlled
clinical studies to suggest that keeping the teeth
clean is an effective means of controlling
periodontal disease.
•In fact, patients are responsible for the success or
failure as long as the dentist has provided oral
prophylaxis and motivated and instructed him in
proper home care procedures.

11. •When the gingiva is inflamed, there is increased
hyperemia, which shows as a deepening of the
normal pink color to red, this is usually associated
with bleeding either on brushing or spontaneously.
• The gingival margin and the interdental papillae
are usually swollen and edematous.
•This results in shiny appearance of the surface with
loss of stippling.
• Mild gingivitis is very prevalent among children
often being limited to loss of stippling, swelling
and slight redness.

14. •In more advanced cases, however, marked redness
with frequent bleeding may occur accompanied
sometimes by soreness and etching, where
inflammation has been present for a long period
there may be an over growth of connective tissue
specially in the anterior region where the gingivae
become rough and irregularly enlarged.

16. •In more severe cases, destruction of the periodontal
ligaments will occur, this may be accompanied by
resorption of the alveolar bone, pocket formation,
loosening and tooth migration.
•At puberty there is sometimes a pronounced
gingivitis showing more swelling and discoloration
than usual but after a time this may tend to improve
although frequently treatment is also required.

20. •Causes of periodontal disease:
These may be conveniently divided into local
and systemic predisposing though naturally, any
particular patient may be affected by more than
one etiological factor.
I. Local factors.
II.Systemic factors.

21. Local factors:
1. The consistency of the diet is considered
important on the basis of functional stimulation
derived from mastication which is an essential
requirement for the normal metabolic activity of
the gingiva and underlying tissues. Soft foods are
detrimental to the periodontium, first because
they do not afford functional stimulation, and
second, they faster accumulation of irritating food
debris at the gingival margin. Bacterial activity in
the food debris around the teeth and gums can
cause damage to the underlying gingival tissues
and initiate gingivitis.

23. 2. Calculus: although important in the adult is
hardly an etiological factor in children since
relatively few exhibit it. In any case one of the
commonest sites for gingivitis in children, the
upper labial segment is rarely affected by
calculus.

25. 3. The process of shedding of deciduous teeth and
eruption of permanent teeth are probably
responsible for much of the gingivitis seen
during the mixed dentition period. The child
will avoid chewing on a loose or painful tooth
allowing deposits to be left on and around the
affected site.

27. 4. Untreated caries, especially in cases of
interproximal and cervical caries due to
increased impaction or lodgment of food debris.
Poorly contoured restorations and overhanging
cervical edges are also a cause of periodontal
disease.

29. 5. Occlusal abnormalities: e.g. crowding of teeth,
open bite, proclined maxillary incisors, and
incompetent lips, are common cause of
gingivitis by interfering with normal function
and allowing food stagnation. Early extraction
of a first permanent molar will prevent the
normal cleansing effect of mastication and allow
food stagnation around the tooth opposite the
space.

31. 6. Prosthetic and orthodontic appliances: constitute
a significant local irritating factor particularly
when poorly fitting or incorrectly designed.

32. Systemic factors:
When planning preventive measures, it is
desirable to consider systemic factors. The
systemic background conditions the gingival
tissue response to the local irritating factors.

33. 1. Endocrinal disorders: diabetes often permits an
increased inflammatory gingival response,
particularly if there is neglected oral hygiene. At
puberty there are often hormonal changes and
temporary upset in the gingival condition
characterized by a rather swollen hemorrhagic
appearance.

34. 2. Drugs: the administration of certain drugs on
long term basis may give rise to gingival
alterations. The anticonvulsant drug “Dilantin”
causes characteristic gingival hyperplasia
starting at the interdental papillae and spreading
over other areas too, occasionally completely
covering the teeth. In some cases the gum is
rather firm and shows little tendency to bleed, in
others a superadded gingivitis is present as well.

36. 3. During acute fevers: such as typhoid and measles,
deterioration of the gingiva may occur due to the
concomitant poor oral hygiene but an
improvement should be shown on recovery from
the fever.

37. 4. Blood dyscrasias, such as agranulocytosis,
leukemia and purpura often exhibit gingival
changes and these may even be the first
symptoms experienced by the patient.

38. 5. Avitaminosis may affect the gingiva;
particularly the lack of vitamin C, which gives
rise to scurvy but nicotinic acid deficiency,
also may precipitate gingival
lesions too.

39. Preventive Measures
1. Dental prophylaxis: it is more important in the
control of periodontal disease than it is in the
control of caries. This is because deposits of
calculus are highly conductive to periodontal
disease and cannot be removed by the patient in
the course of home care. Patients with a
tendency to gingivitis must be observed until it
is known in how many months the accumulation
of hard deposits upon the teeth will pass beyond
the control of home care.

40. Many periodontal patients must receive
dental prophylaxis every 3 months or every 4
months, in addition to whatever more extensive
treatment may be necessary at the hand of the
dentist. Posterior bite-wing X-ray films should
be taken at annual intervals and studied for any
alveolar bone loss.
If calculus forms in a child's mouth, a
thorough prophylaxis should be carried out and
repeated at intervals; in addition, the child's
brushing habits should be checked to try to
prevent any recurrence.

42. 2. Good oral hygiene: the stressing, from an early
age, on the importance of good oral hygiene in
assisting the natural cleansing action of the
mouth is valuable; in addition, it should be
recommended that children eat some hard,
fibrous and fresh foods in addition to the rather
soft diet prevalent today. It must be stressed also
that the toothbrush is really a mouth brush and
the care of the gingivae is just as important as
that of the teeth.

44. 3. Tooth brushing: it is the most commonly
recommended measure for the removal of food
debris and plaque from the teeth mechanically.
On the basis of the motion, methods of brushing
are different, from vertical, horizontal, roll,
circular to scrub method. None of them has been
shown to be superior to others.

45. The thoroughness of plaque and debris
removal depends upon the careful and correct
application of any brushing method rather than
the applied methods itself. The roll technique
mentioned before can be suggested, other
techniques are beneficial particularly when
periodontal disease is existing; these are:

46. A. Charter's method:
The end of the bristles is placed in contact
with the enamel of the tooth surface and the
gingival tissue with the bristles pointing
occlusally at an angle of 45 degree. Much lateral
and downward pressure is then placed upon the
brush and the brush is vibrated gently back and
forth a millimeter or so. This gentle vibratory
procedure forces the ends of the bristles between
the teeth and cleans the interproximal tooth
surfaces very well. This technique also massages
the interdental tissues as well.

48. B. Stiliman's method:
The brush is placed in approximately the same
position as required for the beginning stroke of the
roll method, except that it is nearer the crowns of
the teeth. The handle is vibrated gently in a rapid
but slight mesiodistal movement. This technique
forces the bristles into the interproximal spaces
and handle the teeth in that area very well. It also
adequately massages the gingival tissues. As a
final step of brushing, it is recommended to brush
the dorsum of the tongue with brush. This will
increase its circulation and removes bacteria and
waste products that can cause fetid oris.

50. 4. Devices for entering individual crevices: dental
floss, tooth picks, rubber tips etc, are sometimes
recommended for cleaning areas inaccessible to
the toothbrush. They are beneficial in massaging
the gingival tissues and cleaning the
interproximal spaces (The uses of these devices
are discussed before).
5. Oral irrigation: (discussed before).

51. 6. Early treatment of carious cavities: to avoid
gingival inflammation, caries should be treated as
soon as a cavity is spotted. There is no urgent
"big cavity" to cause wary and non-urgent "little
cavity" warrants no such interest. Caries is caries
in both conditions. Cervical cavities and
interproximal cavities cause irritation of the
neighboring gingival tissue, whereas an open
occlusal cavity causes decreased function of the
same side and results in the accumulation of
debris.

53. • The use of bite-wing films in the early detection
of interproximal lesions is advisable because
such early cavities may be missed on clinical
examination only.
• New restorations should be carefully inserted,
contoured and polished to avoid food impaction
and gingival damage. Old restorations should be
checked for improper contact, overhanging
margins and defect at the tooth restoration
junctional line.

54. 7. Disorders of occlusion: early diagnosis of
occlusal disorders and early treatment by
preventive or interceptive measures will save
the gingiva, the deleterious consequences of
crowding, open bite, cross bite etc.

55. 8. Mouth breathing: this should be treated either by
clearing the air passages (oro-nasal part) by
surgical or medical specialists, or by orthodontic
means as oral screen. The effect of repeated
drying on the gingival tissue will thus be
eliminated.

57. 9. In the presence of prosthetic, surgical or
orthodontic appliances, the patients must be
aware of the role of such appliances in
encouraging the stagnation of debris and
traumatizing oral soft tissues including the
gingiva. It is necessary to maintain good oral
hygiene and cleaning the removable appliances
thoroughly outside the mouth. It is occasionally
suggested to relief the oral tissues by leaving
dentures out at night.

59. 10.Systemic diseases: such as blood dyscrasias,
endocrine disorders and vitamin deficiencies
will need medical attention in addition to local
treatment. Proper oral hygiene will add to the
health of oral and periodontal tissues.

60. Prevention of Occlusal Abnormalities

61. • Preventive orthodontics is that division of the
science and art of dentistry, which deals with the
recognition, prevention, treatment and elimination
of the factors involved in the production of oral
and dento-facial abnormalities.
• Prophylactic orthodontics seeks to create and
maintain for the individual a normal environment
and proper physiologic activity of the teeth, soft
oral tissues and facial and masticatory
musculature, in order to insure, as far as possible
optimum dentofacial development and function.

62. • At present the etiology of malocclusion is not
fully known.
• It is desirable that the general practitioner be
able to recognize early deviations from normal
dentofacial development of his young patients.
• He should then either institute interceptive
measures when appropriate or, watch the child
until orthodontic treatment, if necessary can be
started. He must be watchful of his young
patients to check from about age of 5 onwards
the development of the arches and their
relationship to each other.

63. • The size, shape and quality of the teeth must be
taken into account because crowding which
involves a genetically determine factor such large
teeth and small jaws may involve some difficulty
to resolve.
• It may not be accomplished by appliances, but on
the other hand, the timing of the dentists
involvement is important because later growth of
the jaws may make the problem difficult to
resolve.

65. • During his regular examinations of the child, there
should be careful recording of possibly harmful
habits such as thumb and finger sucking, tongue
thrusting, lip habits, incorrect swallowing patterns
etc.
• Some of the deformities (such as anterior open
bite associated with thumb and finger sucking)
will correct themselves in time, if and when the
child stops the habit, and therefore the dentist
must be aware of the timing for interception.

67. It would, therefore, seem that the dentist
should be able to:
• Understand normal dentofacial growth,
development, and the interrelationship between
jaws and teeth.
• Recognize early deviations from the normal, for
example, delayed eruption of maxillary incisors
due to the presence of supernumerary tooth in
the palate.
• Understand the various etiological factors in
malocclusion.

69. • Recognize the cases, in which early intervention
may be helpful, for example, the removal of
over-retained primary incisors, which are
causing palatal eruption of permanent incisors.
• Recognize, when it is better to wait and delay
orthodontic treatment or to consult an
orthodontist to help in the prevention of
malocclusion.

71. The following may be considered as being
within the scope of preventive attention:
• Retained deciduous teeth: an ankylosed tooth in
particular may cause malalignment of the
permanent successor and may cause lack of
development of the alveolar process.
• Poor restorative attention, loss of contacts due to
caries or inadequately contoured fillings may
lead to loss of space posteriorly while
overcontoured posterior contact areas may cause
anterior crowding.

74. • Loss of deciduous posterior contact areas may
lead to encroachment on the space required for
the eruption of permanent successors. Attention
should be paid to the necessity for provision of a
space maintainer but careful observation over a
period may determine whether this is necessary
or not.

76. • Cross bites in wholly deciduous arches do not
require orthodontic interference as the permanent
arches are not usually corrected by this early
treatment.
• Unerupted or erupted supernumerary teeth may
cause malalignment.
• Individual teeth which are in incorrect
labiolingual relationship with their opponents
may be corrected by simple bite-plane appliance,
once in the correct relationship no retention will
be required.

78. Ectopic eruption of the first permanent molars.
The first permanent molar presents a classic
problem of ectopic eruption. The mesially
positioned molar may cause premature resorption
and exfoliation of the second primary molar. The
problem occurring in approximately 3 % of the
population.
Age: 5- 6 years.
Sex: boys more than girls.
Site: it may occur in more than one quadrant in the
same mouth. Maxillary molars are most frequently
involved.
Diagnosis: full mouth radiographs at 5 or 6 years
of age are essential for early diagnosis.

80. • Complication: a child may occasionally complain
of neuralgic pain in the area of impaction
resulting probably from the resorption of the
distal portion of the second primary molar, break
in the epithelial attachment that allows the
ingress of oral fluids and resultant pulpal
inflammation.
• If this occurs, the primary tooth must be
removed.

81. • Treatment: although the problem is self-limiting
in two thirds of the cases reported, one third
requires correction.
• When the first permanent molar is partially
erupted, several methods for correction have
been suggested.
• A prefabricated wire separator (brass separating
wire) provides the simplest form of treatment,
the wire (0.5 or 0.6 mm) tightened around the
contact area and retightened every 2 to 3 days.
• The wire will cause disto-occlusal movement of
the first permanent molar, if the contact opens
during treatment to the degree that the wire can
no longer be retained a thicker wire should be
used.

83. • It is often helpful to place a gingival
overextended band on the second primary molar
to provide a smooth guiding surface for the
permanent molars.
• These techniques may be unsatisfactory and the
second primary molars may be severely
damaged and beyond possible treatment.
• In this case, extraction of the second primary
molar and construction of an active appliance to
distalise the first permanent molar into its proper
position prior to the placing of a passive space
maintainer is the treatment of choice.