Periodontal Disease and Overall Health: A Clinician's Guide

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CHAPTER 2 Overview of Periodontal Disease:CHAPTER 2 Causes, Pathogenesis, and Characteristics 11Risk FactorsThere are a number of risk factors associatedwith periodontal diseases. 29-34 Determiningrisk is helpful in developing recommendationsfor prevention and indetermining strategies for the overall managementof periodontitis. It has been recognizedthat the severity and progression ofperiodontal disease varies from individualto individual. Bacteria are essential for theinitiation of the disease, but it is the host responseto the bacterial challenge that determinesthe severity and rate of progression ofthe periodontitis. Therefore, it is the host’simmunologic reaction that determines susceptibilityto the disease.General categories of risk factors associatedwith the development of periodontitisinclude genetic, environmental (e.g., tobaccouse), and acquired risk factors (e.g., systemicdisease). Risk factors (Table 2) and riskreduction strategies (Table 3) should be consideredwhen assessing each patient. 35 Somerisk factors can be modified to reduce apatient’s susceptibility. Environmental factorssuch as tobacco use and stress can bemanaged with smoking cessation and stressmanagement; for acquired factors such assystemic diseases, medications usuallyprescribed by the physician can be used tohelp in the management and control ofchronic disorders (Table 3). The use ofchemotherapeutic agents specifically designedto improve the clinical outcomes ofmechanical treatments for periodontal diseasesmay be particularly useful in the managementof those individuals with single ormultiple risk factors. Risk assessment canTable 2. Risk Assessment for Periodontitis1. Heredity as determined by genetic testing and family history2. Smoking, including frequency, current use, and history3. Hormonal variations such as those seen in:a. Pregnancy, in which there are increased levels of estradiol and progesterone that may change theenvironment and permit virulent organisms to become more destructiveb. Menopause, in which the reduction in estrogen levels leads to osteopenia and eventually osteoporosis4. Systemic diseases such as:a. Diabetes (the duration and level of control are important)b. Osteoporosisc. Immune system disorders such as HIVd. Hematologic disorders such as neutropeniase. Connective tissue disorders such as Marfan’s and Ehlers-Danlos syndromes5. Stress as reported by the patient6. Nutritional deficiencies and obesity that may require a dietary analysis7. Medications such as:a. Calcium channel blockersb. Immunomodulatory agentsc. Anticonvulsantsd. Those known to cause dry mouth or xerostomia8. Faulty dentistry such as overhangs and subgingival margins9. Poor oral hygiene resulting in excessive plaque and calculus10. History of periodontal diseaseSources: J Periodontol 1994;65:260–267. 29 J Periodontol 1995;66:23–29. 30 J Periodontol 1999;70:711–723. 31J Periodontol 2000;71:1057–1066. 32 J Periodontol 2000;71:1215–1223. 33 J Periodontol 2000;71:1492–1498. 34
12 Periodontal Disease and Overall Health: A Clinician's GuideTable 3. Risk Reduction Strategies1. More frequent visits for those with a genetic predisposition; use of pharmacotherapeutics for the2.management of periodontitis2. Smoking cessation using one or more of the six approved regimens; these regimens are rarely2. successful as sole therapies (multiple forms of therapy often are used in combination with2. counseling to achieve success)3. Hormonal variations such as those seen in:a. Pregnancy, which requires good oral care before conception to prevent complications duringa. pregnancy; treatment during pregnancy may be necessary to prevent adverse pregnancy outcomesb. Menopause, which may require hormonal supplements, calcium, and other medications anda. supplements prescribed by the physician to prevent osteopenia4. Systemic diseases that require consultation with the physician include:a. Diabetes (for improved glycemic control)b. Osteoporosis (requiring calcium supplements, bisphosphonates)c. Immune system and hematologic disordersd. Connective tissue disorders5. Stress management; possible referral to a psychologist or psychiatrist6. Nutritional supplementation and weight reduction; possible referral to a nutritionist7. Medications can be changed in consultation with the physician8. Corrective dentistry9. Improved oral hygiene (brushing, flossing, use of antiseptics)10. Occlusal adjustmentsSource: Dent Clin North Am 2005;49:611–636. 35help the practitioner to establish an accuratediagnosis, provide an optimal treatment plan,and determine appropriate maintenance programs.In patients with multiple risk factors,the practitioner may aggressively use pharmacologicadjuncts such as antimicrobialsand host-modulatory therapy in addition tomechanical therapy. It is also important toupdate and assess risk factors for each patienton a regular basis as some of these factorsare subject to change throughout life.ETIOLOGY AND PATHOGENESISOF PERIODONTAL DISEASEInitially, periodontal disease wasthought to be related to aging and was thereforeuniformly distributed in the population,with disease severity being directly correlatedwith plaque levels. Now as a result ofextensive research, it has been shown thatperiodontal disease is initiated by plaque,but the severity and progression of the diseaseis determined by the host response tothe bacterial biofilm. People with severeplaque and calculus accumulation will havegingivitis, but not necessarily periodontitis.On the other hand, certain individuals, despitemaintaining adequate oral hygiene, findthemselves susceptible to aggressive formsof periodontitis, with deep pocketing, toothmobility, and early tooth loss. Clearly, the responseof the periodontal tissues to plaque isdifferent in these two different scenarios. Periodontaldisease does not appear to behaveas a classic infection, but more as an opportunisticinfection. 35 These observations ledresearchers to realize that the host responseto the bacterial challenge, presented by subgingivalplaque, is the important determinantof disease severity. Although plaque bacteriaare capable of causing direct damage to theperiodontal tissues, it is now recognized that
Page 5: ivCONTRIBUTORSSrividya Kidambi, MDA
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