epidemiology and etiology of periodontal disease

7/30/2019 epidemiology and etiology of periodontal disease

1/108

Canadian National Institute of Health Inc.

PeriodonticsDH 240


2/108

LO 2. Discuss the initiation and progression of periodontal

disease including its local and systemic contributing risk factors.


- Analyze common periodontal indices used in the

study of periodontal diseases in a population.

- Analyze epidemiological variables associated with

periodontal disease.

- Explain historical and current theories on theinitiation and progression of periodontal disease.


3/108

Epidemiology of

periodontal disease


4/108


Epidemiology

EPIDEMIOLOGY is the study of health and disease

within the total population(rather than an individual)

and the risk factorsthat influence health anddisease.


5/108

Risk Factors

Risk factors are characteristics that increase

an individuals susceptibility to a disease.

Risk factors are associated with a disease but

do not necessarily cause the disease.


6/108

Heredity

Gender

Physical environment Systemic factors

Socioeconomic status

Personal behavior

Examples of Risk Factors


7/108

Epidemiologists study periodontal disease:

To determine its occurrence in the

population

To identify risk factors for periodontal

disease


8/108


9/108

Disease Prevalence

It is the number of all cases of a disease (both oldand new) that are identified in a specific population

at a given point in time.

For example,cancer prevalence is defined as the

total number of people living with cancer at any point

in time. It includes both people diagnosed with

cancer in the past (who are still alive) as well aspeople recently diagnosed.


10/108

Prevalence vs. Incidence

Incidencethe number ofnew disease cases in apopulation that occurover a period of time. For

example, cancer incidence is the number of new

cases of cancer diagnosed in one year.


11/108

The prevalence of periodontal disease in theadult population is determined by performing

clinical examinations on cross-sections of

groups usingindices.


12/108

Examples of

commonlyused

periodontal

indices

Periodontal screening andrecording

PSR

Gingival indexGI

Gingival bleeding indexGBI

Eastman interdentalbleeding index

EIBI

Community and periodontalindex of treatment needs

CPITN

Measuring Prevalence of Disease (check yourbook on page 84, may be tested on)


13/108

Epidemiology and Periodontal Disease

A large percentage of the adult population has


Epidemiologic research provides current information

about the methods and behaviors successful in

Treating periodontal disease

Preventing periodontal disease


14/108

Variables Associated with PD


Gender

Age

Race

Educational Level and SES

Access to Dental Care


15/108

1) Gender


Males have greater prevalence and severity of

PD over females

Causal? No more likely due to differences in

other variables within the group such as oral

hygiene practices, frequency of dental care etc.
http://images.google.ca/imgres?imgurl=http://iamasonofgod.files.wordpress.com/2008/03/gender.jpg&imgrefurl=http://iamasonofgod.wordpress.com/2008/03/30/a-call-for-a-christian-theology-of-gender-identity-andor-expression/&usg=__L7QpJ0DcQyPC2A7CF-NjkxYgPi0=&h=317&w=380&sz=19&hl=en&start=1&tbnid=Vcavy9Tipk-JoM:&tbnh=103&tbnw=123&prev=/images?q=gender&gbv=2&hl=enhttp://images.google.ca/imgres?imgurl=http://www.su.nottingham.ac.uk/pageassets/volunteering/howtogetinvolved/projects/elderly/elderly.gif&imgrefurl=http://www.su.nottingham.ac.uk/activities2/volunteering/projects/elderly/&usg=__kalycw1Q9femxbVX57_EfNTg0cE=&h=591&w=591&sz=20&hl=en&start=16&tbnid=W5UubY9uebyCKM:&tbnh=135&tbnw=135&prev=/images?q=elderly&gbv=2&hl=en


16/108


Epidemiologic studies have shown that the incidence

(number of NEW cases) of periodontal diseases increases

with age.

Hypothesized that it is likely the result of cumulative effects

of bacterial inflammation of the tissues over many years, or

an increase in exposure to other risk factors, rather than a

reduction in host resistance as a function of the agingprocess.

2) Age
http://images.google.ca/imgres?imgurl=http://www.su.nottingham.ac.uk/pageassets/volunteering/howtogetinvolved/projects/elderly/elderly.gif&imgrefurl=http://www.su.nottingham.ac.uk/activities2/volunteering/projects/elderly/&usg=__kalycw1Q9femxbVX57_EfNTg0cE=&h=591&w=591&sz=20&hl=en&start=16&tbnid=W5UubY9uebyCKM:&tbnh=135&tbnw=135&prev=/images?q=elderly&gbv=2&hl=en


17/108

As an individual lives longer, the chances increase that heor she will be exposed to additional risk factors forperiodontal disease such as systemic illness, medications,

and stress.

Evidence strongly suggests that periodontal health canbe maintained throughout life if local etiologic factors

are controlled.


18/108

Prevalence of Periodontal Disease in Various

Age Groups


19/108

3) Race


Minority racial groups (non-Caucasians) have a

higher prevalence of periodontal disease. Again causal? No could have genetic links

or could be because of the other variables

discussed ie: home care, access to care, etc.


20/108


21/108



22/108



23/108

Individuals who desire or need dental care may not

have access to care.

Examples of barriers to dental care includetransportation to a dental office and the financial

expense of dental care.

Is access to dental care an issue in Canada?

5) Access to Dental

Care


24/108

It is easier to evaluate a population for caries than


Measuring caries is more objective.

Development and disease progression is well known.

Development and disease progression involves only the

tooth structure.

Evaluation of periodontal disease is less specific. Ithas many different VARIABLES.

Difficulties in Measurement of PeriodontalDisease


25/108

Periodontal disease involves hard and soft tissues.

Multiple variables to consider are Tissue color changes and swelling

Loss of bone and supportive structures

Degree of bleeding

Probing depths


26/108

Periodontal disease is one of the most widespread

diseases in adults.

Most individuals who have periodontal disease do notknow that they have it.

Periodontal disease is the leading cause of tooth loss in

adults older than age 45 years.

What Research Shows


27/108


23% of 65-74 year-olds have or have had severe


By age 60-69, less than half of all adults in the

US have retained 21 teeth or more.


28/108


Most adults 25 years of age or older have at

least 2mm or more attachment loss.

Severe periodontitis, with 6mm of attachment

loss affects about 14% of adults ages 45 to 54.


29/108


30/108


31/108



32/108



33/108



34/108



35/108


Control and Progression of

Periodontal Disease


36/108


Disease control of periodontitis

There, so far, have been 4 different theories on

disease control of periodontitis.

They are:1. The CALCULUS theory.

2. The NON-SPECIFIC plaque theory.

3. The BACTERIAL SPECIFICITY theory.

4. The HOST-BACTERIAL theory.


37/108


1. The CALCULUS theory

Before 1960.

Calculus is the primary risk factor, it was a

MECHANICAL irritant to the tissue. Professional focus was on removal of

calculus,debridement was scheduled every 6 months.

Clients were told to brush 3 x daily to remove food

particles.


38/108


The Calculus Theory


39/108


2. NON-SPECIFIC plaque theory

1965-1975

BACTERIAL plaque is the primary risk factor that causesperiodontitis.

All plaque was the same, it was TOO much plaque thatcaused the disease.

Treatment included professional debridement 2-3x per yearand OHI was key

Periodontitis was PREVENTABLE with good oral hygiene.


40/108


NON-SPECIFIC plaque theory


41/108


3. SPECIFIC BACTERIAL PLAQUE

Theory

1975-1985.

All plaque is NOT the same.

Certain plaque is PATHOGENIC.

Periodontitis results from SPECIFIC bacteria found in plaque thatis different in composition from plaque found in health sites.

Treatment: prof. debridement 2-3x per year

The client was instructed in self-care to control plaque. Again, itwas the clients FAULT if disease was not prevented.


42/108


SPECIFIC BACTERIAL PLAQUE

Theory


43/108


4. The HOST-BACTERIAL interaction

theory (Current Perspective)

It is the interaction of the HOST (client) with the

PATHOGENIC bacteria that controls whether or not

periodontitis is present.

A BACTERIAL infection alone is insufficient to result in

periodontitis.


44/108


The HOST RESPONSE plays a critical role in the

tissue destruction seen in periodontitis.

Some clients are at more risk than others.

RISK FACTORS (things that increase host susceptibility

to perio disease) include local oral conditions, habits,

systemic disease, and genetic factors.


45/108


TREATMENT today consists of managing the

BACTERIAL, LOCAL, and SYSTEMIC risk factors forperiodontal disease.

MAINTENANCE appointments are scheduled asfrequently as needed to assist the client in controlling

disease.


46/108


TREATMENT not only consists of periodontal

debridement of root surfaces and the pocketenvironment, but also

Antimicrobial therapy to reduce the bacterial load in

the pocket. This therapy includes: antimicrobialmouthwashes, oral antibiotics, and controlled release

local delivery drug devices.


47/108


Also, when needed, referral to a physician formanagement of systemic disease.

Client NEEDS to be educated about the role ofbacterial plaque in periodontal disease and inplaque control techniques.

The client is NOT at fault for their failure to controlthe disease, instead, risk factors are identified andeliminated or controlled whenever possible.


48/108


The HOST-BACTERIAL interaction

theory


49/108


As we see periodontal diseases havemany factors that contribute to its cause

and progression!


50/108


Progression of Periodontitis

It varies from:

One individual to another.

One site to another in the same persons mouth. One type of periodontal disease to another.

There have been different theories too!


51/108


1 . CONTINUOUS disease

progression theory (historical,

not believed anymore):

1. states that periodontal disease progresses

throughout the mouth in a slow and constant rateover the adult life of the client.

2. All cases of untreated gingivitis lead to periodontitis.

3. All cases of periodontitis progress at a slow andsteady rate of tissue destruction.


52/108



53/108


2. Intermittent Progression Theories

1. Periodontal disease is characterized by periods ofdisease activity (exacerbation) and inactivity(remission).

2. Tissue destruction is sporadic, with short periodsof tissue destruction alternating with periods ofdisease inactivity.

3. Tissue destruction progresses at different rates

throughout the mouth.


54/108


4. Untreated gingivitis does not necessarilyprogress to periodontitis.

5. Susceptibility from person to person appears

to be determined by HOST RESPONSE toperiodontal pathogens.

6. The two theories of intermittent progression

are:-Burst

-Asynchronous Multiple Burst


55/108


- Random Burst Theory:

This theory suggests that clients experience short

periods of tissue destruction ofabout 4-7 monthsalternating with short periods of disease inactivity lasting

for 4-7 months.

Occurring at RANDOM times and at RANDOM sites inthe mouth. It is possible that some sites in the mouth

have worsening bone loss while other sites remain the

same.


56/108



57/108


- Asynchronous Multiple

Bursts theory:

1. This theory suggests that MULTIPLE bursts of

disease activity occur over short periods of time

followed by an indefinite period of remission.

2. Most of the tissue destruction happens during aperiod of a few years.


58/108



59/108

Implications


How does our understanding of the progression of

PD affect the way we treat PDs?


60/108

Etiology of periodontal

disease


61/108


Multifactorial Etiology

ETIOLOGY is the study of ALL factors that may

be involved in the development of a disease,

including the nature of the disease agent,susceptibility of the client, and the way in which

the agent invades the clients body.

Multifactorial results from the interaction ofmany factors


62/108


Multifactorial Etiology

Periodontitis has a MULTI-FACTORIAL etiology.

Risk Factors for Periodontitis:

1. Dental Plaque Biofilm (Primary risk factor)

2. Host Response to Bacteria

3. Local Contributing Factors

4. Systemic Contributing Risk Factors


63/108



64/108


Well discuss the 4 factors but with emphasis on

local and systemic factors right now.


65/108


1. Primary Risk Factor

Periodontal disease is a BACTERIAL

INFECTION.

BACTERIA need to be present for periodontal

disease to occur.

BACTERIA is a PRIMARY ETIOLOGICAL factor.


66/108

2. Host Response


The way the body reacts to the pathogenic bacteria

is the host response

Complex interaction

Later on we will get further into this risk factor.

(biofilm and host response)


67/108

3. Local Contributing Factors


local nearbyin the mouth

Oral conditions that increase an individuals

susceptibility to periodontal infection in specific sites.

They do NOT initiate perio disease

Dental team should recognize in order to eliminate or

minimize them.


68/108


How do local contributing risk factorscontribute

to the disease process?

3 mechanisms of action:A. Increase plaque retention

B. Increase plaque pathogenicity

C. Cause direct damage to the periodontium


69/108

A. Factors that increase plaque retention


Most often these decrease the effectiveness of

self-care.

Include: Calculus

Tooth morphology


70/108

-Dental Calculus


Covered on its external surface by non-mineralized,

living bacterial plaque

Effects on the periodontium:

Irregular surface harbors plaque

Creates ledges that are difficult or impossible for the clientto self-clean


71/108

-Tooth Morphology


Includes:

Overhanging restorations retains plaque and it difficult

for the client to clean

Untreated tooth decay the untreated defect acts as a

harbor for plaque growth

Tooth grooves or concavities on enamel or root surfaces naturally occurring.

B. Factors that increase plaque


72/108

p q

pathogenicity:


Discussing the qualityof the plaque not the

quantity

Mature plaque the older the plaque the more

pathogenic the bacteria (we will discuss this in

greater detail when we cover Biofilm)

Genetics some people have more pathogenic

bacteria than others.

C. Factors that cause direct damage to the


73/108

g

periodontium:


Includes:

Occlusal trauma

Food impaction

Patient habits (factitious)

Faulty restorations or appliances


74/108

-Occlusal Forces


Functional normal forces produced during

mastication

Parafunctional results from tooth-to-tooth contact

when NOT eating (ie bruxing or clenching)

Treatment can include fabrication of an appliance or

occlusal equilibration (adjustment)


75/108

-Occlusal trauma


Occurs when excessive occlusal forces cause

damage to the periodontium

Can cause bone resorption allowing more rapid

destruction of perio tissues in existing perio disease.

Signs and Symptoms:

Clinical tooth mobility, pressure sensitivity, migration

Radiographic widened PDL space, bone resorption


76/108



77/108

-Food Impaction


Repeated food impaction can alter the gingival

contour resulting in open embrassures that thenlead to more food and/or plaque retention.

Can be the result of restorations sometimes can be

corrected with restorations.


78/108



79/108

-Patient Habits


Tongue Thrusting (can cause excessive lateral

pressure on the periodontium)

Mouth Breathing (dries out the tissue)

Improper use of dental aids (ie toothpicks)

-Faulty Restorations or Appliances


80/108

-Faulty Restorations or Appliances


Crown margins when placed too close to the

crest of the bone it is called _________?

Bulky crowns can encroach on the interdental

space and cause damage to the papilla.

Partial Denture clasps can impinge on the gingiva

and retain plaque.


81/108



82/108


4. Systemic Contributing

Risk Factors

Increase the hosts susceptibility or amplify the

host response to periodontal disease

Include:

I. Tobacco use V. Stress

II. Diabetes mellitus VI. Genetic influences

III. Osteoporosis VII. AIDS

IV. Hormone alteration VIII. Systemicmedications

I T b U


83/108

I. Tobacco Use


One of the most important RFs in development AND

progression of perio.

Smokers are 2.6 - 6 times more likely to exhibitperiodontal destruction

12-14 times more likely to have SEVERE attachment

loss

Smokers have more pathogenic bacteria present intheir plaque biofilms AND form more calculus due

the oral environment.


84/108

Effects of Smoking on Prevalence and Severity


85/108

of Periodontal Disease



86/108


II Di b M lli


87/108

II. Diabetes Mellitus


3 types Type 1 insulin dependant 5-10%

Type 2adult onset 90-95% diet, exercise,

medication/insulin controlled Gestational Diabetes only during pregnancy

affects approx. 4% of pregnancies

Oral manifestations: Burning tongue

Xerostomia

Candidiasis


88/108

P i d t l Di d Di b t


89/108

Periodontal Disease and Diabetes

Elevated blood sugar levels suppress thehosts immune response and results in:

Poor wound healing

Susceptibility to recurrent infections

Periodontal disease is often consideredthe 6th complication of diabetes and mayplace the individual at risk for futurediabetic complications

*From The Amer Acad of

Periodontology, pamphlet"

III O t i


90/108

III. Osteoporosis


Loss of bone density

Postmenopausal lack of estrogen

Long term steroid treatments or marked lack of activity

Can exacerbate bone resorption


91/108


A quick word on Bisphosphonates


92/108


Bisphosphonate medications are primarily used to treat cancer

(intravenous [IV] administration) and osteoporosis (oral

administration).

They act by inhibiting osteoclastic activity, which leads to less

bone resorption, less bone remodeling, and less bone turnover.

In the treatment of osteoporosis, the goal is to harness

osteoclastic activity to minimize or prevent bone loss and in

many cases, to increase bone mass by creating an advantage

for osteoblastic activity.

There is an association between bisphosphonates and

osteonecrosis of the jaws in some patients.

Osteonecrosis presents as exposed alveolar bone

i t l ft d t l d


93/108


occurring spontaneously or after a dental procedure.

The sites may be painful with surrounding soft tissue

induration and inflammation. Infection with drainage

may be present.

IV H Alt ti


94/108

IV. Hormone Alteration


Most obviously in puberty, pregnancy and menopause.

Strong hormone fluctuations can alter the hostresponse to plaque biofilmproducing an exageratedinflammatory response.

Definitely still a secondary RF (cannot occur in theabsence of plaque)

Should stress the importance of proper self-care.

Menopause can cause decreased hormones and result

in xerostomia, altered taste and burning sensations.


95/108


V Stress (psychosocial)


96/108

V. Stress (psychosocial)


May be the result of behavior changes:

Poor home care

Poor diet

Increase in parafunctional habits such as smoking or

bruxism.

Stress can also alter the host immune response

increasing the susceptibility to periodontal infections.

VI Genetics


97/108

VI. Genetics


Could be related to:

Genetically more pathogenic bacteria (Downs

Syndrome) Genetically determined immune response

Genetically defective immune cells (PMNs)

VII AIDS


98/108

VII. AIDS


Immunodeficiency

Could include other immunodeficiency diseases (ie:

Lupus, or medication induced immunosuppression)

High risk of: NUG, NUP and LGE

VIII Systemic medications


99/108

VIII. Systemic medications


Possible Effects

1. Alteration of plaque composition (ie increase sugar

or PH)

2. Effect on gingival tissues (ie hyperplasia)

3. Effect on salivary flow (saliva is antimicrobial,

reparative, and physically cleansing)


100/108

Cyclosporine-Influenced Gingival Overgrowth

Nutritional Deficiencies


101/108

Nutritional Deficiencies


They exacerbate the severity or extent of periodontal

disease. Good nutrition results in:

Increased resistance to infection.

Strengthened epithelial barrier.

Ability to repair damaged tissue. The lower the calcium intake, the more severe the



102/108


Summary Periodontitis has a multifactorial etiology.

Bacterial plaque is the primary etiological risk

factor, but other risk factors increase a clients

susceptibility to periodontal disease.

These other risk factors are:

Local risk factors

Systemic risk factors


103/108


Scenario Two individuals who have exactly the same level

of plaque control and exactly the same amount of

plaque accumulation do not necessarily developthe same severity of periodontal disease.

How do you explain this fact?


104/108


Scenario A new client presents in the office. After initial

assessment, the following is noted:

The client has poor plaque control, generalized

calculus deposits, poorly controlled diabetes, ahistory of smoking cigarettes, and inadequate dietary

intake of calcium.

How would you characterize the likelihood that the

client will develop periodontitis in the future? What might you tell the client about their situation?

Review


105/108

Review


What are the 4 theories of the etiology of periodontal

disease?

What are the 3 perspectives on periodontal disease

progression?

Review


106/108

Review


What are the 4 main risk factors that make up the

MULTIFACTORIAL etiology of periodontal disease?

Which one is PRIMARY?

What does that mean?

Review


107/108

Review


What does a widened PDL space mean?

What could be the cause of a burning tongue

sensation?

List the adverse affects that smoking has on the

periodontium.

Resources


108/108

Resources

Nield-Gehrig, Jill S. (2008) Foundations of Periodontics for the

Dental Hygienist (2nd ed.). Baltimore, Philadelphia: LippincottWilliams and Wilkins.

Weinberg, Westphal, Froum and Palat (2006). Comprehensive Periodontics

for the Dental Hygienist (2nd Edition). Pearson Prentice Hall.

epidemiology and etiology of periodontal disease

Documents