prevention of periodontal diseases

1. Associate Professor, Pediatric
Dentistry and Dental Public
Health ,
Faculty Dentistry
Cairo University
Presented by
SARA AHMED MAHMOUD

2. Biology of
periodontal
diseases

3. NORMAL PERIODONTAL
STRUCTURE
 The periodontium is composed of the
gingiva, periodontal ligament,
cementum, and alveolar bone with the
accompanying vascular and nerve
supply.

4. Periodontal Disease:
 It is an inflammatory disease of the
supporting tissues of the teeth caused by
specific microorganisms or groups of
microorganisms, resulting in a progressive
destruction of the periodontal ligament
and alveolar bone with pocket, recession,
or both.
 This definition describes both:
Gingivitis Periodontitis

5. GINGIVITIS:
 It is an inflammation of soft tissue without
apical migration of the junctional
epithelium.

6. PERIODONTITIS:
 It is an inflammatory disease results in
apical migration of the junctional
epithelium.

7.  Risk factors /
indicators for
periodontal
disease :
 A- local factors.
 B- environmental
factors.
 C- systemic
factors .
 D- economic
factors.
Periodontal
Disease and
Associated
Risk Factors

8. Risk model for periodontal
disease:
Periodontal
disease
Environmental
Local
Economic
Systemic
✓ Smoking
✓ Nutrition
✓ Obesity
✓ Stress
✓ Bacteria
✓ Morphology
✓ Restorations
✓ Host-
response
✓ Socioeconomic status
✓ Access to care
✓ Age
✓ Gender
✓ Immunodef-
iciency
✓ Genotype
✓ Hormonal

9. Local factors

10. Bacterial plaque biofilm:
 Accumulation of BPB at the gingival
margin is the primary factor responsible for
the initiation of gingivitis.
 Nonspecific plaque hypothesis.
 Specific plaque hypothesis.
 Porphyromonas gingivalis.
 Bacteroides forsythus.
 A. actinomycetemcomitans.

11.  Calculus : which serves as a reservoir for
bacterial plaque -------- risk factor for
periodontitis.

12. Environmental
factors

13. Smoking :
 Smokers were 4 times more likely to have
periodontitis than those who have never
smoked.
 Moderate and severe periodontitis.
 > 5mm attachment loss.

14.  Smokeless tobacco:
❖ Oral leukoplakia and carcinoma.
❖ NOT generalized effect of PD.
❖ Localized attachment loss and recession.

15.  Age.
 Gender
 Genetic factors:
 Hormonal
( pregnancy
gingivitis)
 Emotional stress
 Nutritional status.
 Immune
dysfunction
Systemic factors

16.  Age:
* nonmodifiable factor
*++++ severity and prevalence with age
 Gender:
*nonmodifiable factor
*♂ > ♀ ( oral hygiene, health behavior,
access to dental care).

17.  Genetic factors:
*nonmodifiable factor.
 The concept of inheritance of risk for
disease and provide evidence that
genetic factors influence clinical
measures of gingivitis, probing pocket,
depth, attachment loss, and interproximal
bone height.

18.  On the basis of strong evidence for the
familial nature of aggressive periodontitis,
children, and siblings of those diagnosed
with aggressive disease may be at
increased risk, should be encouraged to
receive regular periodontal evaluations
and preventive care.

19.  Genetic alterations can result in
abnormalities in the host response.
❖ Neutrophil abnormalities.
❖ Monocytic hypersensitivity to lipopolysaccharide
stimulation.
Genetic
alterations
Hyporesponsiveness
Hyperresponsiveness
Microbial
challenge

20.  Hormonal ( pregnancy gingivitis)
periodontal infection and inflammation are
associated with pregnancy due to
hormonal modification (+++ progesterone)
✓ Erythema
✓ Edema
✓ Hyperplasia
✓ +++bleeding
✓ pocket depth.
✓ Tooth mobility

21.  Emotional stress
✓ Interfere with normal immune function.
✓ Inability to cope with stress
+++ incidence and severity of disease
Smoking
Poor oral hygiene

22.  Nutritional status.
❖ Determines the immune response to a
microbial challenge.
❖ Diet influences dental plaque biofilm
development and composition.
Eg:
• Protein energy malnutrition
• Vitamin C and E
• Body fat

23.  Immune dysfunction.
❑ HIV and AIDS.
❑ Diabetes (type 1 and type 2).
❑ Pregnant women.
 Epidemiologic studies reveal correlations
between oral infections and
cardiovascular disease.
 In some analysis, the only factor that
significantly served as a predictor for
developing Alzheimer’s disease was the
presence of periodontal disease.
 Osteoprosis is another potential risk factor
for periodontitis.

24. Economic factors

25.  Gingivitis and poor oral hygiene are
related to lower socioeconomic status.
• ---dental awareness
• Limited access to dental care

26.  Higher socioeconomic status are thought
to practice consistent preventive
behaviors and avoid more unhealthy
behaviors( smoking, poor diet, poor oral
hygiene)

27.  Therefore, lower SES alone does not result
in increased risk for periodontal disease
after adjusting for the risk factors such as
smoking and poor oral hygiene

28. Preventive
Strategies
for
Periodontal
Disease

29.  Personal oral hygiene measures and
periodic professional care.
 Combining professional and self care with
chemotherapeutic agents to reduce
periodontal microbiota

30. Mechanical removal of
supragingival plaque
 Manual tooth brushing

31. Manual tooth brushing
 The primary device for routine oral
hygiene and mechanical plaque
removal.
❖ Toothbrushing:
✓ Remove plaque and food debris.
✓ ----gingival inflamation.
✓ ---- no of MO within the biofilm.
✓ ----pathogens in the subgingival microbiota.

32. Toothbrush Designs
 They have been modified and refined
during the years in order to be more
effective in plaque removal and
improved oral health.

33.  Scientific evidence fails to confirm
the advantage of any particular
manual toothbrush design.
 Therefore, the choice of a
toothbrush is a matter of personal
preference.
 ie: to address a specific patient
need.

34. Powered(automatic)tooth
brushes:
 To improve oral hygiene and make oral
self care easier.
 More effective.
 More attractive (pt and dental
professionals).
 Reduce gingival inflammation.
 Aid in interdental cleaning.

35.  Motion: side to side or vibrate rotate 360
degree in one direction, rotate clockwise
and counter-clockwise (rotation-
oscillation).
 Indication: orthodontic patients, children
with physical or mental impairments, adult
with disabilities or limited dexterity.

36. Tooth brushing methods
 The benefit of any one brushing method
has not been subjected to evidence-
based evaluation.

37. Adverse effects of tooth brushing
 Gingival inflammation.
 Gingival recession ( localized or
generalized)
Gingival
recession
Root caries
and
dentine
hypersensitivity

38. Interdental plaque removal:
 Periodontal diseases more frequently
affect interproximal areas.
 Interdental mechanical plaque removal is
necessary for most patients.

39. Dental floss
Floss holder

40. Floss threader

41. Automatic flossing devices
Waterpik dental floss

42. Single tufted brush
Wooden wedges
Interdental brush

43. Tongue cleaning
 The tongue surface harbors larger
numbers of bacteria, including known
pathogens.

44. Frequency of plaque control:
 The effectiveness of oral hygiene
depends on:
❖ Oral health
needs.
❖ Personal
factors.
❖ Systemic D.
❖ Environmental
F.
❖ Local F.
❖ SEF.
Frequency

45. 2-CHEMOTHERAPEUTIC
AGENTS FOR PLAQUE
CONTROL

46.  The use of chemical agents to prevent
periodontal diseases is based on the
hypothesis that this disease follows an
infectious disease model and that onset
and severity are related to a group of
pathogens.

47.  ADA Seal of Acceptance program
reviews therapeutic claims, including
caries prevention, antiplaque,
anticalculus, or antigingivitis properties,
and reduction in dental hypersensitivity.

48.  Current evidence supports the use of
approved toothpastes and oral rinses only
as an adjuncts to mechanical plaque
control.
 Eg: Chlorhexidine Gluconate oral rinse.
Essential Oils oral rinse.

49. Chlorhexidine Gluconate oral
rinse.
 The most effective antiplaque
agent currently approved.
 Broad spectrum antiseptic
(bactericidal).
 Substantivity= inhibitory effect on
plaque formation for 12-14 hours.
 Dis adv: alteration of taste.
staining(teeth, rest,tongue)
Used 30min after tooth
brushing---- sodium lauryl
sulfate and calcium

50. Essential Oils oral rinse
 Phenol-related essential
oils.
 Moderate effectiveness in
plaque control if mouth
rinse 2/day.
 Burning sensation.
 GIT disturbance ( pt take
metronidazole)

51. Dentifrices
 For delivery of antimicrobial agent
 Interaction between biocide and other
ingredient--------limited this application.

52. 1- Triclosan
 Synthetic phenol derivative in nonionic
form (antiseptic).
 Approved by ADA as antigingivitis ,
antiplaque agent.

53. 2- Stannous fluoride
 Bactericidal action.
 ----gingivitis.
 Stannous fluoride dentifrice carry the ADA
seal of acceptance only for anticaries
activity.
 Extrinsic staining.

54. Anticalculus agents
 Calculus (tartar ) is a mineralized dental
plaque.
 Periodontitis ------ due to retention of
dental plaque on its rough surface.

56.  Outcomes are enhanced when
professional plaque removal includes oral
hygiene instructions and recall is based on
estimation of future disease risk.

57.  Scaling and root planing.
 Remove subgingival
calculus and plaque.
 Disrupt the dental biofilm.
 Free root surface from
microbial byproducts.
 EBD: ---- pocket depth,
--- inflammation,
stabilizing periodontal
attachment levels

58.  Antimicrobial agents are used to
enhance the effectiveness of scaling and
root planing.
 Antimicrobials may be : local or systemic.

59. 1- Local delivered chemotherapeutics
 Controlled- or sustained-
release antimicrobials.
 Their effectiveness is
ensured when
clearance or washing
away of the active
ingredient by the
gingival cervicullar fluid.

60.  CHx digluconate in a biodegradable gel
wafer ( Perio Chip).

61.  Tertracycline fibers(Actisite).

62.  Minocycline in a powder form in a
bioadhesive , bioresorbable
polymer(Arestin).

63. 2- Systemic delivered chemotherapeutics
 In this case the drug will treat the person
of the mouth not otherwise affected by
subgingival debridement.
 It is used as adjuncts for periodontal
debridement.
 Used in : poor response to therapy.
aggressive form of disease.

64.  Adverse effects:
 Colonization of subgingival niche with
drug resistant microbial strain.
 Allergic reaction.

65.  Supportive periodontal therapy or
 Periodontal recall
❖ Professional care for those who have
previously received treatment of
periodontal disease.
✓ Prevent recurrence of disease.
✓ Stop disease progression.
✓ Reduce the loss of teeth.

66.  Timing:
✓ Every 4-6 months ( high standard of
oral hygiene and little inflammation)
✓ Every 3 months ( chronic
periodontitis)
✓ Timing of periodontal maintenance
is reevaluated at each recall visit.

67. Restoration
with over
hanging
margins or
open contact
Ill fitting
dental
prostheses
Over
contoured
crown
Food
impaction
site
malocclusion Furcation
involvement
Root surface
concavitis

68.  Tooth related local factors should be
corrected , when possible, through
professional care as a part of
comprehensive periodontal disease
prevention.

70. TOBACCO CESSATION
 Dental professionals have a responsibility
to ask about patients’ tobacco habits
and offer tobacco cessation advise,
assistant, and support with
pharmacotherapy

72.  The rational for host modulation is to
change or block the pathway that lead
to periodontal tissue destruction.
Non steroidal
antiinflammatory drugs
Collagenase inhibitor s
Bone sparing agent
(ttt osteoporosis)
Doxycycline hyclate
(periostat)

74.  A way to remember the basics to develop
a preventive plan.
 Purpose: to establish a sequence of
educational and clinical services decided
on in collaboration with the patient that
will be effective for reducing the risk for
disease and promoting oral health.

75. Provide complete information.
 Inform patient of
the finding of the
clinical
examination,
present oral health
status, causes of
periodontal
disease, and
personal risk factors.

76. Realistic goals identified.
 Work with the patient to set a realistic
short and long term goals for improving
oral health and changing oral health
behaviors.

77. Explain professional care options
 Discuss the professional services available
to solve current problems ,maintain oral
health, and reduce risk for disease.

78. Variety of choices offered
 Offer a patient a choice of plaque
control devices, oral care products, and
self care methods.

79. Encourage the patient.
 Increase the patient’s self-confidence in
changing oral self-care behaviors through
encouragement, reinforcement, skill
building and other methods.

80. Negotiate frequency of self care.
 Support the patient in assuming
responsibility for personal health and
negotiate a schedule for the self-care
regimen.

81. Time reevaluation appropriately.
 Sequence appointment to reinforce new
skills and evaluate progress toward
achieving short-term goals.