systemic risk factors
conditions/diseases that increase individuals susceptibilities to periodontal infection by modifying/amplifying host response to bacterial infection
diabetes
chronic disease which body doesn't produce insulin or properly use insulin
undiagnosed is the only time its a perio risk factor
insulin
hormone used to convert sugars, starches, food into energy
diabetic pts and perio disease
3x more likely to develop
glucose increases=perio health decreases
poor response to NSPT/surgery
increased risk acute perio abscess, attachment loss, bone loss
hypergylcemia and perio
increased glucose in crevicular fluid
bacteria thrive & alter biofilm colonies
diabetes and immune response
reduced PMN function & defective chemotaxis allow bacteria to grow
significantly higher IL-1B and PGE2
Hyperglycemia affects collagen synthesis, maturation, maintanence
excessive formation of accumulated gycaltion end-products
AGE and diabetes
derived from reaction of glucose/proteins
involved in biological process relating to collagen turnover
collagen cross linked w/ AGE formation
less likely to have repair normally
non perio oral complications of diabetes
reduced salivary flow
candidiasis
burning mouth/tongue
perio abscess
leukemia
cancer beginning in blood cells
abnormal WBC that don't function properly
crowd out normal WBC, RBC and platelets
types: chronic or acute and myeloid/lymphoid
myeloid leukemia
myelogenous
affects myeloid cells
lymphoid leukemia
affects lymphoid cells
lymphocytic
medical treatment
complex/varies on type, age, extent, symptoms
chemo
radiation
bone marrow transplant
biological therapy
chemotherapy effects
suppresses growth of bad and good cells
effects cell with higher turnover rate (mucosa)
can cause sensitive mouth that is easily infected and likely to bleed
oral complications of leukemia
associated gingivitis
swollen, glazed, spongey tissue
red/deep purple
spontaneous bleeding of lips, gingiva, tongue
gingival enlargement: papilla to margin to attached
oral mucositis
xerostomia
oral mucositis
inflammation caused by chemo killing rapidly dividing cells
mucosa lifespan is only 10-14 days so cells are dividing faster than they can regrow
causes sloughing & ulcerations
xerostomia caused by radiation
causes damage to salivary glands
implications of leukemia for DH
early diagnosis because first sign is in mucosa
look for: gingival swelling with no reason combined with facial swelling, tiredness, poor appetite, lethargy, skeletal pain
RDH involvement in leukemia
immunosuppression may cause serious oral infections
necessary care before, during, after chemo to prevent poor oral condition & further systemic disease
use soft toothbrush or dental sponge
chlorohexidine for mucositis
oral capsaicin
temporary relief for mucositis pain
active ingredient: chilli pepper
anti inflammatory
monitor use bc has sugar
what to eat with mouth sores
soften food with liquid- broth, milk
add olive oil to food to make slippery
use blender to mash fruit and veggies
use saliva substitute
smoothies, soup, mashed potatoes
what to avoid with mouth sores
caffeine
alcohol
tobacco
alcohol rinse
acidic food- orange, grapefruit, lemon
spicy food
salty
raw veggies
rice, chips, bread, cakes
HIV
causes weak immune system
perio and HIV
Linear gingival erythema
Necrotizing perio disease
linear gingival erythema
LGE
2-3mm gingival marginal band of intense erythema in free gingiva
may extend to attached
may be localized but commonly generalized
lack of response important in diagnosis
LGE RDH implications
monitored to prevent permanent damage
frequent recare
initial tx: cholorhexidine, DHT, antibiotics
drugs interactions with antiretroviral therapies
flucanozole, ketoconazole, intraconozole, metronidazole, ciprofloxicin, midazolam, trialzam
hormone flucations
puberty, pregnancy, menopause
puberty
increased levels of estradiol for females, testostorone for male
sex hormones cause blood circulation to gingiva and response to irritants
clinical features of puberty
end when puberty does
accumulation of plaque
red, inflammed, BOP
reversible with meticulous care
DH implications of puberty
daily self-care
professional care
recommend: antimicrobial rinse, antibiotic, perio therapy
pregnancy
inflammation increases with ANY plaque
increases in 2/3 trimester
enhanced estrogen=sensitive to biofilm
produce: estradoil, estriol, progesterone
elevated progesterone during pregnancy
enhance capillary permeability
dilation=increased exudate and edema
change in immune system for pregnant women
high levels of estrogen/progesterone suppress response to biofilm
PMN chemotaxis & phagocytosis reported to be depressed **less helpers!!
pregnancy gingivitis
gingival inflammation initiated by plaque biofilm and exacerbated by hormonal changes in the second and third trimesters of pregnancy
Pregnancy-associated pyogenic granuloma
localized overgrowth in interdental gingiva
benign, not painful
surgically removed if continues after pregnancy ends
probe depths, BOP and crevicular fluids increased
implications for DH of pregnancy
education on homecare, LA, xray safety
prenatal vitamins, folic acid to eliminate cleft
erosion from sickness: suggest small meals, avoid brushing after vomitting
menopause/post menopause
periodontium effected by hormones
dry mouth, burning mouth
decline of estrogen: cause bone loss
gingivostomatitis: gingiva bleed rapidly, abnormally pale, dry, shiny, erythemous
osteoporosis
reduction of bone mass resulting in susceptibility to fracture
does NOT initiate periodontitis but an adjunct
osteopenia
lower than average bone density no increase in susceptibility to fracture
bisphosphonates
commonly prescribed to inhibit bone resorption of systemic osteoporosis
osteonecrosis of the jaw
painful exposed bone in mouth that fail to heal after procedure
increased risk of bone and tooth loss
implication of DH menopause
calcium supplement
weight bearing excercise
meticulous oral care
estrogen+biofilm=host response=increased bone resorbing cytokines, monocytes, macrophages, osteoblasts
genetic risk factors
Chediak-Higashi syndrome
leukyocyte adhesion defiency syndrome
job syndrome
Papillon-Lefevre syndrome
Chron disease
acute monocyte leukemia
cyclic & chronic neutropenia-PMN malfunction more susceptible to perio
down syndrome & perio
orofacial features- under developed midfacial region (lip, tongue, palate)
maxilla, nose are smaller
proganathic occlusion
mouth breathing, tongue protrusion
strong gag reflex
palate highly vaulted
drooping lip
drooling
malocclusion and down syndrome
delayed eruption of permenant teeth
underdevelopment of maxilla
open bite=disease/caries
medical problems of pt w down syndrome
congenital heart defect
GI abnormalities
infection
respiratory problem
child leukemia
abnormal PMN
perio implications of down syndrome
often develop severe, aggressive perio
plaque, deep perio pocket, inflammation
lose teeth in teens
missing one salivary gland
down syndrome and immune response
impaired PMN chemotaxis/phagocytosis
impaired cellular motility of gingival fibroblasts that promote healing/regeneration
sugar containing meds
cough drops, liquid meds, syrups, tonics, chewables, antacids tablets
cause: enamel demineralization
salivary flow and meds
400+ meds cause dry mouth
drug induced gingival enlargement
anticonvulsants, immunosuppresants, Ca channel blockers
fibroblasts overproduce collagen matrix stimulated by inflammation
anticonvulsants
tx of epilespy
gingival overgrowth
interpapillae become firm
good biofilm control: pink, firm, rubbery
poor biofilm control: red, edematous, spongey
acute periodontal conditions
conditions commonly characterized by having sudden onset & rapid course of progression
Pain/discomfort
may be unrelated to pre-existing perio
periodontium abscess
acute infection involving circumscribed collection of pus in periodontium
gram negative, anaerobic
similar bacteria to periodontitis
pain is constant & localized
possible tooth mobility
radiographic bone loss
vital pulp
mastication difficulty, bad taste
s
causes of periodontium abscess
blockage of oriface of pocket
pre-existing perio pocket
forcing object into pocket: toothpick
incomplete calculus removal: site w/ deep pocket, coronal tissue heals & tightens preventing drainage
pulpal abscess
infection of tooth pulp that can extend to periodontium
cause: death of pulp: trauma or decay
gingival abscess
primarily limited to gingival margin & interdental papilla w/o deeper involvement
foreign object forced through sulcus
can be healthy
periodontal abscess
affects deeper perio tissue and gingiva
pre-existing perio disease
pericoronal abscess
perio abscess involving tissue around crown of partial erupted tooth
tissue cover occlusal of 3 molar
tissue flap (operculum) get infected
symptoms of pericoronal abscess
pain w/ occlusion
limited opening
swelling, redness
fever
lymphadenopathy
steps managing pt with abscess
1. establish drain path for pus
2. anthetized tissue
3. drain through pocket or surgery
4. perio instrumentation
5. adjustment of occlusion
6. possible antibiotics
7. salt water rinse
8. possible pain med
tx of pericoronal abscess
1. anesthetize
2. drain same as other abscess
3. through perio instrumentation
4. irrigate area of operculum w/ saline
5. possible antibiotics
6. possible extraction
Necrotizing Ulcerative Gingivitis
acute infection of periodontium limited to gingival tissue
aka: vincent, trench, ANUG
cause of NUG
poor nutrition
fatigue
psychosocial factors
systemic disease
drug/alcohol use
HIV
signs of NUG
punched out papilla
papilla destroyed interdentally
pseudomembrane gray/white
lots of blood
raw CT
dead cells, bacteria, debris
characteristic of NUG
oral pain
necrotic, punched out papilla
bleeding
pseudomembrane
swollen lymph nodes
discomfort
extreme halitosis
fever
treatment of NUG
3 appointments
appointment 1 of NUG treatment
remove pseudomembrane w/ irrigation
supragingival debridement
gentle homecare
cholorhexidine rinse
appointment 2 of NUG treatment
2 days after initial treatment
subgingival debridement
further self care instruction
appointment 3 of NUG tx
5 days after initial
further debridement
possible antibiotics
surgical reshaping of gingiva
Necrotizing ulcerative periodontitis
similar to NUG but effects deeper tissue including alveolar bone
can result from untreated NUG
formation of bone squestrum (dead bone)
tx: med consult and referral to periodontitis
Primary Herpetic Gingivostomatitis
viral infection of HSV1
painful
contagious during vesicular stage
virus is contained in clear liquid
PHG clinical signs
oral pain w/ eating
swelling
gingival bleeding
vesicles, ulcerations w red halo
fever
discomfort
swollen lymph nodes
beginning of wound healing
replace inflammed cells with collagen
healing surfaces consists of moderate inflammed CT tissue covered w granulation tissue
layered neutrophils
clot
regeneration
replace lost structure through new cells
this is our goal
hemostatis/clot formation
15 sec-1 min
epinephrine released from platelets
release cytokines
call PGE for vasodilation
sequence of wound healing
1. fibrin overlying CT (mesh)
2. CT produces granulation tissue
how is granulation tissue produced
proliferating CT w/ increased mitotic activity
-Fibroblast (3-5 days)
-endothelial cells fill in from edges of wound (0.5mm daily)
-undifferentiated mesochymal cells
extrinsic pathway
platelets cover by gylcoproteins so they don't stick and cause stroke
platelets go to injured epithelium with holes
platelets swell, become irregular shapes and sticky to stick into holes
forms prothrombic activator via injury
calcium is needed to turn pr
nutrition and clot formation
vitamin k help liver to make clotting factors
warfarin inactivates vitamin k
intrinsic pathway
comes in contact with blood
bleeding on probing
vitamin k/calcium activates bleeding factors
thrombin activates factor x and phospholipids help prothrombin activation=mesh
inflammatory phase
phase 2
5 signs: pain, swelling, heat, redness, loss of function
PMN first responders
macrophages replace after 4 days
Proliferation
stage 3
angiogenisis/granulation formation
granulation tissue penetrates thin clot
fibers extend from cementum to unite with new collagen formed by gingival fibroblasts
epithelium attach at original height
stimulation of collagen to get tensile strength
angiogenisis
blood vessel creation
maturation
last stage
scare
nutrition from blood
not as strong as original tissue
layers of wound
clot, neutrophils, granulation tissue, CT
host modulation therapy
altering pts defense response to help body defenses limit damage caused by disease
importance of host modulation
can help in periodontits
cost effective
biochemical mediators
stimulated by bacteria, causes inflammatory response
anti inflammatory mediators
biochemical mediators that are protective
help keep infection from doing serious harm
cytokines, IL4, IL10
bacterial challenge is great=damage
proinflammatory mediators
can damage periodontium
MMP, cytokine, prostnoids, prostaglandin E, interleukins
tetracycline as a host mod
doxycycline
non antibiotic dose (subantimicrobial)
decreases effects of enzyme collaganase/MMP
can inhibit progression of perio
20mg 2x daily
low side effects
NSAIDS as a host mod
treat pain and inflammation
reduce tissue inflammation by inhibiting PGE2
inhibit osteoclasts
takes up to 3 years to slow bone loss
if they stop taking there is risk of accelerated loss
Bisphosphonates as a host mod
inhibit bone resorption by altering osteoclast activity
not approved bc ONJ risk
statin meds as a host mod
simvastatin, atoravastatin
some protection against inflammation
primary intention
union of 2 granulation surfaces
clot fills space
PMNs show up at edge of wound at 24 hrs
48 hrs epithelial cells fuse edges
fills in with fibrin ends w/ scar
ex: sutures, paper cut
secondary intention
one surface does not have granulation tissue
epithelium cover part of wound
larger clot
depression at end of healing
ex: extraction site
Healing rate of epithelium
5mm daily
healing rate JE
5 days
healing rate SE
7-10 days
healing rate surface epithelium
10-14 days
healing rate CT
21-28 days
healing rate bone
4-6 weeks
new attachment prevention
to attach coronally cementum and collagen must have access to tooth surface
cementum is acellular and does not allow fibers to attach
alveolar crest fibers and transeptal fibers prevent fibroblasts and cementoblasts in PDL to access tooth surface coronal
healing by epithelial adaption
closing adapted but not attached
when probing you won't enter
how we heal after NSPT and why they need again
clinical signs of healing
no bleeding, no inflammation
decreased probe depth
more gram + anaerobes
JE healing
epithelium grows apically
JE grows until it gets to healthy collagen CT
reattachment healing
ideal b/c less susceptible to NSPT again
reestablish soft tissue infterface on surface
union of CT to root surface
JE shorter
tooth avulsed and put back in
new attachment healing
ideal w/ surgery
form new cementum, JE, CT
root conditioning to stimulate cementum
small amount of JE
remove JE, crest and transseptal fibers bc block attachement
gain access to PDL- fibroblast, cementoblasts
keyes technique
hydrogen peroxide to kill perio pathogens
acupuncture and dentistry
used as anesthetic
no rxns
no numbness
less post op pain
dental phobia natural help
hypnosis
biofeedback
relaxation
mind/body
cranberries
antiinflammatory
can help fight cares
polyphenols
Echinecea
stimulates t-cells and interferons
vitamin c and e
decreases gingival inflammation
gingko balboa
decreases gingival inflammation
magnesium citrate
increases muscle function
perio natural meds
aloe vera
blood root
calendula
echinecea
golden seal
grapefruit seed extract
decay reducation with natural meds
alfalfa
dandelion
horsetail
plankton
tooth pain and natural med
clove oil-dry socket
garlic
lemon balm
licorce
propolis
increase salivation and natural med
yohimbe
oil pulling
homecare supplement not replacement
1 Tbsp for 20 min
picks up microbes in gum and tubules lipid pathogen attracted to oil
swish until milky white
5 categories of alternative medicine
alternative medical systems
mind-body interventions
biologically based therapies
energy therapy
manipulative & body based therapy
holistic
support health before there is a problem
heal physical, mental, spiritual
natural interaction w/ anticlotting meds
Dong quai
Omega 3
gingko
vitamin e
danshen
aloene in garlic
ginger
anise
fucus
st. johns wort
american gingseng
natural meds that are anticoagulants
ginger
garlic
gingko biloba
gingseng
st johns wort
feverfew side effects
oral ulcers
lip irritant
bleeding
swollen gingiva
garlic, ginseng and gingko side effects
bleeding
kava side effects
oral/lingual involuntary movement
echinecea
tongue numbness
altered taste
st johns wort
xerostomia
natural effects on LA
Kava kava and st johns wort increase effects
cinnamon effects on dental
decrease antibiotics
tetracycline 80%
alternative natural antibiotics
green tea
thyme
wintergreen
hops
horseradish