0ERIODONTOLOGY

#HRIS )RWIN

"RIAN -ULLALLY (ASSAN :IADA

%DITH !LLEN AND 0ATRICK * "YRNE

0ERIODONTICS  2ISK &ACTORS AND

3USCEPTIBILITY IN 0ERIODONTITIS
!BSTRACT 0ERIODONTITIS IS AN INFLAMMATORY CONDITION INITIATED BY MICROBIAL PLAQUE BUT INFLUENCED BY AN ARRAY OF FACTORS THAT AFFECT THE
DEVELOPMENT AND PROGRESSION OF THE DISEASE 4HIS PAPER SUMMARIZES THE MAJOR RISK FACTORS FOR PERIODONTAL DISEASE AND THE POTENTIAL TO
MODIFY SPECIFIC FACTORS
#LINICAL 2ELEVANCE 4HE ASSESSMENT OF PATIENTS WITH PERIODONTAL DISEASES MUST INCLUDE AN EVALUATION OF RISK AND SUSCEPTIBILITY 7HILE
REMOVAL OF BACTERIAL PLAQUE AND PLAQUE RETENTIVE FACTORS REMAINS THE FOCUS OF TREATMENT FOR SUCCESSFUL LONG TERM MANAGEMENT OF
PERIODONTAL DISEASES IT IS ALSO IMPORTANT TO ELIMINATE KNOWN RISK FACTORS
$ENT 5PDATE    

4HE CONCEPT OF RISK 2ISK FACTORS 2ISK DETERMINANTS

4HE PREVALENCE OF A DISEASE
IS DEFINED AS THE NUMBER OF CASES IN A
GIVEN POPULATION AT A SPECIFIC POINT IN
TIME )N THE CASE OF PERIODONTAL DISEASE
PREVALENCE DATA FROM THE .ATIONAL (EALTH
AND .UTRITION %XAMINATION 3URVEY .(!.%3
#HRIS )RWIN 2EADER#ONSULTANT $EPARTMENT
OF 2ESTORATIVE $ENTISTRY 1UEENS 5NIVERSITY
OF "ELFAST 3CHOOL OF #LINICAL $ENTISTRY 2OYAL
6ICTORIA (OSPITAL "ELFAST "4 "0 .ORTHERN
)RELAND "RIAN -ULLALLY #ONSULTANT3ENIOR
,ECTURER $EPARTMENT OF 2ESTORATIVE
$ENTISTRY 1UEENS 5NIVERSITY OF "ELFAST
3CHOOL OF #LINICAL $ENTISTRY 2OYAL 6ICTORIA
(OSPITAL "ELFAST "4 "0 .ORTHERN )RELAND
(ASSAN :IADA 3ENIOR ,ECTURER#ONSULTANT
5NIVERSITY $ENTAL 3CHOOL AND (OSPITAL
7ILTON #ORK 2EPUBLIC OF )RELAND %DITH
!LLEN ,ECTURER $EPARTMENT OF 2ESTORATIVE
$ENTISTRY 5NIVERSITY #OLLEGE #ORK 5NIVERSITY
$ENTAL 3CHOOL AND (OSPITAL 7ILTON #ORK
2EPUBLIC OF )RELAND AND 0ATRICK * "YRNE
,ECTURER $UBLIN $ENTAL (OSPITAL AND
0RACTICE ,IMITED TO 0ERIODONTICS IN $UBLIN
2EPUBLIC OF )RELAND
 $ENTAL5PDATE
3MOKING
$IABETES
3TRESS
$RUGS
3YSTEMIC DISEASE
.UTRITION
4ABLE  2ISK FACTORS AND DETERMINANTS FOR PERIODONTAL DISEASE
))) STUDY IN THE 53 REPORTED  OF
´ YEAR OLDS HAD MODERATE TO SEVERE
PERIODONTITIS %PIDEMIOLOGICAL STUDIES
CARRIED OUT IN DIFFERENT POPULATIONS HAVE
CONFIRMED THIS APPARENT SUSCEPTIBILITY TO
SIGNIFICANT DESTRUCTIVE DISEASE IN A MINORITY
OF ADULTS WITH BETWEEN  AND  OF THE
POPULATIONS AFFECTED 4HE DEVELOPMENT
AND COURSE OF PERIODONTITIS APPEARS TO
BE DEPENDENT UPON SPECIFIC INHERITED
BEHAVIOURAL OR ENVIRONMENTAL CONDITIONS
´ SO CALLED RISK FACTORS 3UCH FACTORS ARE
BIOLOGICALLY LINKED TO THE DISEASE AND OFTEN
IMPLY CAUSALITY 4HE TERM RISK DETERMINANT
'ENETICS
3OCIOECONOMIC STATUS
'ENDER
IS OFTEN USED SYNONYMOUSLY WITH RISK FACTOR
BUT IS BEST RESERVED FOR THOSE FACTORS THAT
CANNOT BE MODIFIED ! NUMBER OF RISK
FACTORS AND DETERMINANTS FOR PERIODONTAL
DISEASE HAVE BEEN IDENTIFIED 4ABLE  
3MOKING
3MOKING IS A MAJOR RISK FACTOR FOR
PERIODONTITIS AND IMPORTANTLY A MODIFIABLE
RISK FACTOR 2ECENT EPIDEMIOLOGICAL DATA
SUGGEST THAT OVER  OF PERIODONTITIS
CASES CAN BE ATTRIBUTED TO CURRENT OR
FORMER SMOKING 4HIS INCREASED PREVALENCE
AND SEVERITY OF DISEASE IN SMOKERS IS NOT
*UNE 

&IGURE  0ERIODONTAL DESTRUCTION IN A YOUNG
SMOKER
&IGURE 0ERIODONTAL ABSCESS IN A POORLY CONTROLLED
DIABETIC PATIENT
RELATED TO POOR PLAQUE CONTROL IN THESE
INDIVIDUALS BUT RATHER TO A DIRECT EFFECT OF
THEIR SMOKING 4HE SEVERITY OF PERIODONTAL
DISEASE IS DIRECTLY RELATED TO BOTH THE
NUMBER OF CIGARETTES SMOKED PER DAY
AND TO THE NUMBER OF YEARS A PATIENT HAS
SMOKED #LINICALLY SMOKERS EXHIBIT REDUCED
GINGIVAL BLEEDING AND INFLAMMATION AND
SHOW DISPROPORTIONALLY GREATER LEVELS OF
PERIODONTAL POCKETING IN THE ANTERIOR
MAXILLARY SEGMENT &IGURE   !LTHOUGH
THE CORRELATION BETWEEN TOBACCO USE
AND PERIODONTAL DISEASE IS STRONG THE
ROLE OF TOBACCO IN DISEASE PATHOGENESIS
REMAINS SOMEWHAT UNCERTAIN 4HERE ARE NO
CONCLUSIVE STUDIES THAT SMOKING ADVERSELY
AFFECTS THE PERIODONTAL TISSUES BY ALTERING
THE MICROBIAL COMPOSITION OF PLAQUE
)MPAIRMENT OF LOCAL NEUTROPHIL FUNCTION
BY TOBACCO SMOKE AND ITS COMPONENTS
IS ONE POSSIBLE MECHANISM UNDERLYING
THIS INCREASED SUSCEPTIBILITY IN SMOKERS
3MOKING MAY ALSO AFFECT THE ABILITY OF THE
PERIODONTAL TISSUES TO HEAL ´ IN STUDIES OVER
 OF PATIENTS WITH REFRACTORY PERIODONTITIS
WERE FOUND TO BE SMOKERS 3TUDIES
SHOWING THAT STOPPING SMOKING IMPROVES
THE OUTCOME OF PERIODONTAL TREATMENT
*UNE 
EMPHASIZE THE IMPORTANT ROLE FOR THE DENTAL
TEAM TO PLAY IN PROVIDING SMOKING CESSATION
ADVICE AND SUPPORT
$IABETES
$IABETES MELLITUS CAN BE DIVIDED
INTO TWO MAIN TYPES
„ 4YPE  DIABETES FORMERLY INSULIN
DEPENDENT DIABETES MELLITUS )$$- IS
CAUSED BY THE DESTRUCTION OF THE INSULIN
PRODUCING ` CELLS OF THE PANCREAS THROUGH
AN AUTOIMMUNE RESPONSE POSSIBLY
TRIGGERED BY A VIRAL INFECTION
„ 4YPE  DIABETES FORMERLY NON INSULIN
DEPENDENT DIABETES MELLITUS .)$$-
RESULTS FROM DEFECTS IN THE INSULIN MOLECULE
OR THE BODYS ABILITY TO RESPOND TO INSULIN
THUS REPRESENTING IMPAIRED INSULIN FUNCTION
RATHER THAN DEFICIENCY
$IABETES HAS LONG BEEN
CONSIDERED A RISK FACTOR FOR PERIODONTAL
DISEASE 4YPE  DIABETICS HAVE AN INCREASED
RISK OF DEVELOPING PERIODONTITIS WHILE
THE SEVERITY OF THE PERIODONTAL DISEASE
INCREASES WITH THE INCREASED DURATION OF
DIABETES )N STUDIES CARRIED OUT ON 0IMA
)NDIANS A POPULATION SUFFERING FROM A VERY
HIGH INCIDENCE OF 4YPE  DIABETES DIABETIC
SUBJECTS HAD A SIGNIFICANTLY GREATER RISK OF
PROGRESSIVE BONE LOSS COMPARED TO NON
DIABETIC SUBJECTS 4HIS INCREASED RISK WAS
GREATER AMONGST YOUNGER INDIVIDUALS -ORE
SPECIFICALLY SUBJECTS WITH POORLY CONTROLLED
DIABETES HAD A SIGNIFICANTLY HIGHER RISK OF
DISEASE PROGRESSION ODDS RATIO  
COMPARED TO WELL CONTROLLED SUBJECTS ODDS
RATIO    )MPORTANT FACTORS CONTRIBUTING
TO PERIODONTAL DISEASE SEVERITY INCLUDE
„ 4HE DEGREE OF DIABETIC CONTROL
„ 4HE AGE OF ONSET AND
„ 4HE DURATION OF THE DISEASE &IGURE  
4HE BIOLOGICAL MECHANISMS
CONTRIBUTING TO THE DEVELOPMENT OF
PERIODONTAL DISEASE IN DIABETIC PATIENTS
ARE COMPLEX INVOLVING THE DYSREGULATION
OF POLYMORPH FUNCTION ALTERED COLLAGEN
METABOLISM AND MICROVASCULAR DAMAGE
$EVELOPMENT OF FOOT ULCERS IS A COMMON
FINDING IN DIABETIC PATIENTS 4HESE CHRONIC
WOUNDS SHARE MANY PROPERTIES WITH THE
ULCERATED PERIODONTAL POCKET INCLUDING
THE INABILITY TO REPAIR )NDEED THESE TWO
CONDITIONS ARE REMARKABLY SIMILAR AND SHARE
PATHOGENIC MECHANISMS
3EVERAL STUDIES HAVE SHOWN
THAT THE TREATMENT OF PERIODONTAL DISEASE
0ERIODONTOLOGY
IN DIABETIC PATIENTS CAN HAVE A BENEFICIAL
EFFECT ON DIABETIC CONTROL -ECHANICAL
THERAPY COMBINED WITH SYSTEMIC
TETRACYCLINE ANTIBIOTICS IMPROVED BOTH
THE HEALTH OF THE PERIODONTAL TISSUES AND
GLYCATED HAEMOGLOBIN LEVELS A MEASURE OF
GLYCAEMIC CONTROL  4HUS THE RELATIONSHIP
BETWEEN DIABETES AND PERIODONTAL DISEASE
MAY WELL BE BI DIRECTIONAL ´ DIABETES
ACTING AS A RISK FACTOR FOR PERIODONTITIS AND
UNTREATED PERIODONTAL DISEASE BEING A RISK
FACTOR FOR POOR GLYCAEMIC CONTROL 3UCCESSFUL
TREATMENT AND MAINTENANCE OF PERIODONTAL
HEALTH IN DIABETIC PATIENTS SHOULD BE A
MAJOR GOAL TO IMPROVE BOTH THE ORAL AND
GENERAL HEALTH OF THE PATIENT
3TRESS
3TRESS IS KNOWN TO IMPACT ON
THE NORMAL FUNCTIONING OF THE IMMUNE
SYSTEM )NVESTIGATIONS INTO A POTENTIAL ROLE
FOR STRESS AS A RISK FACTOR FOR PERIODONTAL
DISEASE ARE FEW IN NUMBER .EVERTHELESS
DATA FROM THESE STUDIES TEND TO SUPPORT A
LINK BETWEEN OCCUPATIONAL STRESS AND THE
PROGRESSION OF PERIODONTITIS  3PECIFICALLY
THOSE PATIENTS WITH INADEQUATE COPING
BEHAVIOURS ARE AT GREATER RISK OF DEVELOPING
ADVANCED DISEASE .EGATIVE LIFE EVENTS
UNEMPLOYMENT AND SOCIAL STRAIN HAVE
ALSO BEEN LINKED TO INCREASED LEVELS OF
PERIODONTITIS &URTHER STUDIES HAVE SHOWN
THAT SPECIFIC PERIODONTAL PATHOGENS
CAN UTILIZE STRESS HORMONES TO STIMULATE
GROWTH AND EXPRESSION OF VIRULENCE FACTORS
PROVIDING ANOTHER POTENTIAL MECHANISM
LINKING STRESS LEVELS WITH PERIODONTITIS
$RUGS
4HE ANTICONVULSANT PHENYTOIN
&IGURE  $RUG INDUCED GINGIVAL ENLARGEMENT
$ENTAL5PDATE 
 0ERIODONTOLOGY
#ONDITION
()6 INFECTION
"LOOD DYSCRASIAS
EG NEUTROPENIA AGRANULOCYTOSIS
LEUKAEMIA
3CURVY
0REGNANCY
4ABLE  3YSTEMIC DISEASES AND PERIODONTITIS
#ONDITION
0APILLON ,EFEVRE SYNDROME
#HEDIAK (IGASHI SYNDROME
,AZY LEUCOCYTE SYNDROME
,!$ SYNDROME
#HRONIC GRANULOMATOUS DISEASE
$OWNS SYNDROME
%HLERS $ANLOS SYNDROME
(YPOPHOSTASIA
4ABLE  'ENETIC CONDITIONS AND PERIODONTAL DISEASE
THE IMMUNOSUPPRESSANT CYCLOSPORIN AND
CALCIUM CHANNEL BLOCKING DRUGS SUCH
AS NIFEDIPINE AND AMLODIPINE ARE WELL
KNOWN TO INDUCE GINGIVAL OVERGROWTH
IN SUSCEPTIBLE PATIENTS &IGURE   4HE
OVERGROWTH CLASSICALLY BEGINS IN THE
INTERDENTAL PAPILLAE AND CAN DEVELOP TO
INCLUDE THE WHOLE ATTACHED GINGIVA #ELL
BASED STUDIES ON THE DEVELOPMENT OF
GINGIVAL OVERGROWTH INDICATE A COMPLEX
INTERACTION BETWEEN THE DRUGS HOST
FIBROBLASTS AND INFLAMMATORY CELLS RESULTING
IN AN INCREASED DEPOSITION OF CONNECTIVE
TISSUE SUPPORTING A HYPERPROLIFERATIVE
EPITHELIUM 0LAQUE CONTROL BECOMES
INCREASINGLY DIFFICULT RESULTING IN AN
ADDITIONAL OEDEMATOUS INFLAMMATORY
COMPONENT TO THE OVERGROWTH (OWEVER
ALTHOUGH THESE DRUGS CAN HAVE A MAJOR
EFFECT ON GINGIVAL TISSUE THERE IS NO CLEAR
 $ENTAL5PDATE
%FFECT ON PERIODONTAL TISSUES
)NCREASED RISK OF NECROTIZING CONDITIONS BUT NO
EVIDENCE OF INCREASED PROGRESSION OF PERIODONTITIS
2EDUCED NUMBERSFUNCTION OF
NEUTROPHILS AND MACROPHAGES INCREASING
RISK OF .5' AND PROGRESSIVE
PERIODONTITIS
6ITAMIN # DEFICIENCY CAUSING ABNORMAL COLLAGEN
TURNOVER RESULTING IN INCREASED
RISK OF PERIODONTAL ATTACHMENT LOSS
)NCREASED RISK OF GINGIVAL INFLAMMATION
PREGNANCY GINGIVITIS
$ISORDER
$EFECTS IN NEUTROPHIL ADHESION
)NCREASED CATHEPSIN PRODUCTION
!BNORMAL PHAGOCYTE CHEMOTAXIS
2EDUCED LEUCOCYTE CHEMOTAXIS
2EDUCED LEUCOCYTE ADHESIONPHAGOCYTOSIS
!BNORMAL LEUCOCYTE INTRACELLULAR KILLING
!BNORMAL LEUCOCYTE CHEMOTAXIS AND PHAGOCYTOSIS
#OLLAGEN DEFECT
#EMENTAL DEFECT
EVIDENCE THAT THEY ALSO PREDISPOSE TO AN
INCREASED RISK OF PERIODONTITIS
-ANAGEMENT OF GINGIVAL
OVERGROWTH SHOULD BEGIN BY INVESTIGATING
A POSSIBLE CHANGE IN MEDICATION IN
CONSULTATION WITH THE PATIENTS PHYSICIAN
4HIS ALONG WITH MECHANICAL CLEANING AND
METICULOUS PLAQUE CONTROL CAN RESULT IN
A SIGNIFICANT REDUCTION IN THE SIZE OF THE
GINGIVAL TISSUES 3URGICAL REMOVAL OF RESIDUAL
REDUNDANT TISSUE MAY ALSO BE REQUIRED
3YSTEMIC DISEASE
2ATHER THAN VIA THE DIRECT EFFECT
OF BACTERIA AND BACTERIAL PRODUCTS THE TISSUE
DESTRUCTION ASSOCIATED WITH PERIODONTITIS
RESULTS FROM THE HOST RESPONSE TO BACTERIAL
INSULT !S SUCH PERIODONTAL DISEASE COULD
BE DESCRIBED AS @BYSTANDER DAMAGE IN THE
WAR BETWEEN PERIODONTAL PATHOGENS AND
THE IMMUNEINFLAMMATORY RESPONSE !NY
SYSTEMIC CONDITIONS THAT AFFECT THE ABILITY
OF THE HOST TO MOUNT A DEFENCE CAN IMPACT
ON DISEASE PROGRESSION !S SHOWN IN 4ABLE
 SUCH CONDITIONS INCLUDE HAEMATOLOGICAL
DISEASES INFECTIONS NUTRITIONAL DEFICIENCIES
AND HORMONAL CHANGES
.UTRITION
2ESEARCH INTO A POTENTIAL ROLE
FOR DIET AND NUTRITION AS RISK FACTORS FOR
PERIODONTAL DISEASE IS AT A RELATIVELY EARLY
STAGE 3EVERE 6ITAMIN # DEFICIENCY LEADS TO
@SCORBUTIC GINGIVITIS COMMONLY KNOWN AS
SCURVY PRESENTING WITH ULCERATIVE GINGIVITIS
GINGIVAL HAEMORRHAGE RAPID PERIODONTAL
POCKET FORMATION AND TOOTH LOSS 6ITAMIN
# IS AN IMPORTANT ANTIOXIDANT AND PLAYS AN
IMPORTANT ROLE IN THE INHIBITION OF REACTIVE
OXYGEN SPECIES 2/3 WHICH CONTRIBUTE
TO TISSUE DAMAGE IN PERIODONTAL DISEASE
(OWEVER STUDIES INVESTIGATING A LINK
BETWEEN DIETARY 6ITAMIN # AND PERIODONTAL
DISEASE HAVE PRODUCED CONFLICTING
RESULTS )N THE .(!.%3 ))) STUDY  THE
ASSOCIATION BETWEEN DIETARY 6ITAMIN # AND
PERIODONTITIS WAS WEAK ALTHOUGH A LOW
6ITAMIN # INTAKE IN SMOKERS WAS ASSOCIATED
WITH A HIGHER RISK OF DISEASE
'ENETIC FACTORS
3TUDIES ON PERIODONTAL DISEASE
IN MONOZYGOTIC AND DIZYGOTIC TWINS RAISED
TOGETHER OR APART HAVE DEMONSTRATED
THAT GENETIC FACTORS PLAY A MAJOR ROLE IN
DETERMINING DISEASE SEVERITY  ! ROLE FOR
GENETIC FACTORS HAS ALSO BEEN SUPPORTED
BY CLINICAL OUTCOMES IN PATIENTS WITH
SYNDROMES AND DISEASES ASSOCIATED WITH
SEVERE PERIODONTITIS 4ABLE  
)N RECENT YEARS THE ROLE OF
GENETIC POLYMORPHISMS AS RISK DETERMINANTS
FOR PERIODONTAL DISEASE HAS BEEN THE FOCUS
FOR MANY STUDIES 0OLYMORPHISMS ARE
NOT FRANK MUTATIONS IN A GENE BUT EXIST
THROUGHOUT THE GENOME AND CAN AFFECT
EXPRESSION LEVELS OF THE GENE PRODUCT
7HILE STUDIES HAVE BEEN PERFORMED ON
POLYMORPHISMS IN THE GENES ENCODING
4.& _ 6ITAMIN $ RECEPTOR )G' RECEPTORS
AND . ACETYLTRANSFERASE MOST WORK HAS
CENTRED ON THE INTERLEUKIN  ),  GENE
CLUSTER ),  IS THE MAJOR PRO INFLAMMATORY
CYTOKINE REGULATING PERIODONTAL
INFLAMMATION ),  NOT ONLY ACTIVATES BOTH
*UNE 

!NATOMICAL RISK FACTORS
4OOTH POSITION
)ATROGENIC RISK FACTORS
4ABLE  ,OCAL RISK FACTORS FOR PERIODONTAL DISEASE
&IGURE  'ROOVE ON THE PALATAL SURFACE OF A
MAXILLARY LATERAL INCISOR
THE INFLAMMATORY AND IMMUNE RESPONSES
TO BACTERIAL VIRULENCE FACTORS BUT ALSO
STIMULATES THE RELEASE OF HOST PROTEOLYTIC
ENZYMES AND OSTEOCLASTIC ACTIVATION THAT
RESULTS IN PERIODONTAL TISSUE BREAKDOWN
3INGLE NUCLEOTIDE POLYMORPHISMS 3.0S
IN THE ),  GENE CAN HAVE MAJOR EFFECTS
ON EXPRESSION LEVELS OF THE PROTEIN WITH
EXPRESSION OF A SPECIFIC GENOTYPE ASSOCIATED
WITH HIGHER LEVELS OF ),  PRODUCTION
IN THESE INDIVIDUALS )N  +ORNMAN
AND COLLEAGUES REPORTED AN ASSOCIATION
BETWEEN A SPECIFIC ),  GENE PATTERN AND
INCREASED SEVERITY OF PERIODONTITIS 3INCE
THEN NUMEROUS STUDIES HAVE INVESTIGATED
THIS PROPOSED LINK BETWEEN GENETIC MAKE
UP AND PERIODONTAL DISEASE INCLUDING
THE DEVELOPMENT OF THE 0ERIODONTAL
3USCEPTIBILITY 4EST PERFORMED AS A SIMPLE
BLOOD TEST 4HESE STUDIES HAVE SHOWN
THAT WHILE ),  MAY PLAY A ROLE IN DISEASE
*UNE 
%NAMEL PEARLSPROJECTIONS
'ROOVES &IGURE 
&URCATIONS
'INGIVAL RECESSION
-ALALIGNMENT
#ROWDING
4IPPING
-IGRATION
/CCLUSAL FORCES
2ESTORATION OVERHANGS
$EFECTIVE CROWN MARGINS
0OORLY DESIGNED PARTIAL DENTURES
/RTHODONTIC APPLIANCES
SUSCEPTIBILITY MANY SUBJECTS WITH THE
),  GENE POLYMORPHISM ASSOCIATED WITH
INCREASED PRODUCTION OF ),  DO NOT DEVELOP
PERIODONTITIS )T SEEMS CLEAR THAT RATHER
THAN PERIODONTAL DISEASE BEING CAUSED BY
A SINGLE GENE POLYMORPHISM MANY FACTORS
ARE INVOLVED IN THIS COMPLEX DISEASE AND THE
),  POLYMORPHISM ACTS AS A CONTRIBUTORY
BUT NON ESSENTIAL RISK FACTOR
3OCIO ECONOMIC STATUS
3OCIO ECONOMIC STATUS IS
A COMPLEX MULTI FACETED PARAMETER
#ONSEQUENTLY STUDIES INVESTIGATING THE
RELATIONSHIP BETWEEN SOCIO ECONOMIC STATUS
AND PERIODONTAL DISEASE CAN BE DIFFICULT TO
INTERPRET .EVERTHELESS STUDIES HAVE SHOWN
THAT ADVANCED DISEASE CORRELATES WELL WITH
EDUCATIONAL STATUS )T HAS BEEN SUGGESTED
THAT THE BETTER PLAQUE CONTROL AND
INCREASED FREQUENCY OF DENTAL ATTENDANCE
SEEN IN INDIVIDUALS WITH A HIGHER SOCIO
ECONOMIC STATUS MAY EXPLAIN THE DECREASED
PREVALENCE OF PERIODONTAL DISEASE SEEN IN
THIS GROUP
'ENDER
! CONSISTENT FINDING IN
EPIDEMIOLOGICAL STUDIES ON PERIODONTITIS
HAS BEEN AN INCREASED LEVEL OF DISEASE IN
MEN 4HE REASONS FOR THIS GENDER DIFFERENCE
REMAIN UNCLEAR BUT ARE THOUGHT TO BE
0ERIODONTOLOGY
RELATED TO POORER PLAQUE CONTROL AND LOWER
DENTAL ATTENDANCE RATES IN MALES RATHER THAN
TO A GENETIC FACTOR
4OOTH RELATED FACTORS
4HE FACTORS OUTLINED ABOVE
RELATE TO AN INCREASED RISK OF DEVELOPING
PERIODONTITIS AT THE LEVEL OF THE INDIVIDUAL
0ATTERNS OF PERIODONTAL DISEASE INDICATE
THAT SPECIFIC SITES AT SPECIFIC TEETH HAVE AN
INCREASED RISK OF ATTACHMENT LOSS THAN OTHER
SITES IN THE SAME DENTITION ! NUMBER OF RISK
FACTORS RELATED TO THE TOOTH ARE SHOWN IN
4ABLE 
-ANY OF THESE FACTORS ARE
OBVIOUS AND RELATE TO AN INCREASED RISK
OF PLAQUE RETENTION OFTEN DUE TO THE
INACCESSIBILITY TO CLEANING 4HE ROLE OF
OCCLUSAL FORCES IN PERIODONTAL DISEASE
PROGRESSION MERITS FURTHER DISCUSSION
/CCLUSAL TRAUMA
! TRAUMATIC INCISAL OVERBITE CAN
RESULT IN LOCALIZED GINGIVAL RECESSION ON
THE PALATAL ASPECTS OF THE UPPER INCISORS OR
LABIAL ASPECT OF THE LOWER INCISORS AS A RESULT
OF THE SHEARING ACTION OF THE TEETH &IGURE
  4HIS SITUATION CAN OCCUR IN SEVERE #LASS ))
DIVISION  MALOCCLUSIONS OR IN ASSOCIATION
WITH THE LOSS OF POSTERIOR SUPPORT
#ONTINUING TRAUMA CAN LEAD TO LOSS OF
TOOTH SUBSTANCE )NITIAL TREATMENT REQUIRES
PROTECTION OF THE REMAINING TISSUE THROUGH
PROVISION OF AN OCCLUSAL SPLINT $EFINITIVE
TREATMENT IS OFTEN DIFFICULT AND MAY INVOLVE
ORTHODONTIC THERAPY ORTHOGNATHIC SURGERY
OR FULL MOUTH REHABILITATION
/CCLUSAL TRAUMA TO TEETH HAS
BEEN DEFINED AS BEING PRIMARY WHEN THE
&IGURE  ,OCALIZED GINGIVAL RECESSION ON THE
PALATAL ASPECTS OF MAXILLARY INCISORS
$ENTAL5PDATE 
 0ERIODONTOLOGY

COMPLEXES BASED ON A LARGE NUMBER OF INSULIN DEPENDENT DIABETES MELLITUS AND

0ORPHYROMONAS GINGIVALIS
4ANNERELLA FORSYTHENSIS
4REPONEMA DENTICOLA
#AMPYLOBACTER RECTUS
&USOBACTERIUM NUCLEATUM
0REVOTELLA INTERMEDIA
%IKENELLA CORRODENS
!CTINOBACILLIS ACTINOMYCETEMCOMITANS
4ABLE  0ERIODONTAL PATHOGENS AS DESCRIBED BY
3OCRANSKY ET AL
AFFECTED TEETH HAVE A HEALTHY PERIODONTIUM
OR SECONDARY WHEN THE AFFECTED TEETH HAVE
EXISTING PERIODONTAL DISEASE #URRENT THINKING
SUGGESTS THAT OCCLUSAL INTERFERENCES CAN
ACCELERATE BONE LOSS AROUND THOSE TEETH WITH
EXISTING DISEASE #LINICALLY IT IS IMPORTANT THAT
OCCLUSAL INTERFERENCES BOTH IN CENTRIC OCCLUSION
AND LATERAL EXCURSIVE MOVEMENTS ARE REMOVED
BY SELECTIVE GRINDING &OR PATIENTS WITH A
KNOWN BRUXISM HABIT AN OCCLUSAL GUARD CAN BE
USED TO PROTECT THE TEETH
-ICROBIAL FACTORS
!LTHOUGH OVER  BACTERIA HAVE
BEEN IDENTIFIED IN PERIODONTAL POCKETS ONLY
A RELATIVELY SMALL NUMBER HAVE BEEN SHOWN
TO BE INTIMATELY LINKED WITH THE DISEASE
PROCESS 3OCRANSKY ET AL HAVE EXAMINED THE
RELATIONSHIP BETWEEN BACTERIAL SPECIES AND
PERIODONTAL DISEASE 5SING CLUSTER ANALYSIS
THEY IDENTIFIED EIGHT MAJOR GROUPS OF BACTERIAL
PLAQUE SAMPLES FROM PATIENTS WITH A RANGE
OF PERIODONTAL DISEASES 4HESE AUTHORS
CATEGORIZED BACTERIAL SPECIES INTO COLOUR CODED
GROUPS BASED ON THEIR PATHOGENECITY 4ABLE
 AND A VERY STRONG CASE CAN BE MADE FOR
IMPLICATING THESE BACTERIA AS RISK INDICATORS FOR
DESTRUCTIVE PERIODONTAL DISEASE
3UMMARY
0ERIODONTITIS CAN THUS BE
CONSIDERED A DISEASE WHICH SIGNIFICANTLY
AFFECTS A SEGMENT OF THE POPULATION WITH A
PRIMARY BACTERIAL AETIOLOGY BUT IN WHICH THE
NORMAL BALANCE BETWEEN PATHOGENS AND HOST
IS DISTURBED BY ENVIRONMENTAL ANDOR HOST
DERIVED FACTORS LEADING TO PROGRESSION OF THE
DISEASE -ULTI LEVEL RISK ANALYSIS IS REQUIRED
DURING PATIENT EXAMINATION TO IDENTIFY THOSE
RISK FACTORS IMPORTANT TO EACH INDIVIDUAL CASE
)N TURN TREATMENT OF PERIODONTAL DISEASE MUST
INCLUDE BOTH DEBRIDEMENT OF THE PERIODONTAL
POCKET AND ELIMINATION OF THE RISK FACTORS
WHERE POSSIBLE
2EFERENCES
 4OMAR 3, !SMA 3 3MOKING ATTRIBUTABLE
PERIODONTITIS IN THE 5NITED 3TATES FINDINGS
FROM .(!.%3 ))) * 0ERIODONTOL  
´
 +ENNEY %' +RAAL *( 3AXE 32 *ONES * 4HE
EFFECT OF CIGARETTE SMOKE ON HUMAN ORAL
POLYMORPHONUCLEAR LEUKOCYTES
* 0ERIODONT 2ES   ´
 -C&ARLANE '$ (ERZBERG -#
7OLFF ,& (ARDIE .! 2EFRACTORY
PERIODONTITIS ASSOCIATED WITH ABNORMAL
POLYMORPHONUCLEAR LEUCOCYTE
PHAGOCYTOSIS AND CIGARETTE SMOKING
* 0ERIODONTOL   ´
 4AYLOR '7 "URT "! "ECKER -0 'ENCO 2*
3HLOSSMAN - +NOWLER 7# 0ETTITT $* .ON
ALVEOLAR BONE LOSS PROGRESSION OVER TWO
YEARS * 0ERIODONTOL   ´
 'ROSSI 3' 3KREPCINSKI &" $E#ARO 4
:AMBON ** #UMMINS $ 'ENCO 2*
2ESPONSE TO PERIODONTAL THERAPY IN
DIABETICS AND SMOKERS 4HE RELATION
OF PERIODONTAL INFECTIONS TO SYSTEMIC
DISEASES * 0ERIODONTOL  
´
 'ROSSI 3' 3KREPCINSKI &" $E#ARO 4 ET AL
4REATMENT OF PERIODONTAL DISEASE IN
DIABETICS REDUCES GLYCATED HEMOGLOBIN
* 0ERIODONTOL   ´
 ,INDEN '* -ULLALLY "( &REEMAN 2 3TRESS
AND THE PROGRESSION OF PERIODONTAL
DISEASE * #LIN 0ERIODONTOL  
´
 &REEMAN 2 'OSS 3 3TRESS MEASURES AND
PREDICTORS OF PERIODONTAL DISEASE ´ A
PRELIMINARY COMMUNICATION #OMM $ENT
/RAL %PIDEMIOL   ´
 #HAPPLE ),# 2EACTIVE OXYGEN SPECIES AND
ANTIOXIDANTS IN INFLAMMATORY PERIODONTAL
DISEASE * #LIN 0ERIODONTOL  
´
 -ICHAELOVICZ "3 !EPPLI $ 6IRAG *'
+LUMP $' (INRICHS *% 3EGAL ., "OUCHARD
4* 0IHLSTROM ", 0ERIODONTAL FINDINGS
IN ADULT TWINS * 0ERIODONTOL  
´
 -ICHAELOVICZ "3 $IEHL 32 'UNSOLLEY *#
3PARKS "3 "ROOKS #. +OERTGE 4% ET AL
%VIDENCE FOR A SUBSTANTIAL GENETIC BASIS FOR
RISK OF ADULT PERIODONTITIS
* 0ERIODONTOL   ´
 +ORNMAN +3 #RANE ! 7ANG (9 ET AL
4HE INTERLEUKIN  GENOTYPE AS A SEVERITY
FACTOR IN ADULT PERIODONTAL DISEASE * #LIN
0ERIODONTOL   ´
 3OCRANSKY 33 (AFFAJEE !$ #UGINI -!
3MITH # +ENT 2, -ICROBIAL COMPLEXES IN
SUBGINGIVAL PLAQUE * #LIN 0ERIODONTOL
  ´

!BSTRACT
!2% $%.4!, )-0,!.43 !3 35##%33&5, LITERATURE /NE OF THE REASONS FOR THIS SUCCESS OPERATIVELY CAREFUL DESIGN AND REDUCED
!3 )3 #,!)-%$ IS OF COURSE THE VERY CAREFUL CASE SELECTION LOADING WITH TRIPODIZATION DURING FUNCTION
3UCCESS OR FAILURE OF DENTAL IMPLANTS OF PATIENTS REQUIRING SUCH PROSTHESES AND A COMMITMENT TO REGULAR RECALL WITH
! LITERATURE REVIEW WITH TREATMENT 4HIS PAPER GIVES A ENHANCED ORAL HYGIENE PROCEDURES POST
CONSIDERATIONS *! 0ORTER AND *! VON COMPREHENSIVE REVIEW OF THE POSITIVE AND PLACEMENT
&RAUNHOFER 'ENERAL $ENTISTRY   NEGATIVE FACTORS IN PREDICTING IMPLANT !NYONE CONSIDERING INTRODUCING
n SUCCESS OR FAILURE )T CONSIDERS SOME IMPLANTS TO THEIR PORTFOLIO OF PATIENT
WAYS IN WHICH THE LATTER FACTORS MAY BE TREATMENT OPTIONS WOULD FIND THIS PAPER
-OST PRACTITIONERS PLACING DENTAL IMPLANTS OVERCOME BOTH BEFORE DURING AND AFTER EXTREMELY USEFUL
ARE ABLE TO QUOTE THE EXTREMELY HIGH IMPLANT PLACEMENT SUCH AS SMOKING 0ETER #ARROTTE
INCIDENCE OF SUCCESS REPORTED IN THE DENTAL CESSATION AND IMPROVED ORAL HYGIENE PRE 'LASGOW $ENTAL 3CHOOL
 $ENTAL5PDATE *UNE