controversiesinperio

8/2/2019 controversiesinperio

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CONTROVERCONTROVER

SIES INSIES IN

PERIODONTIPERIODONTI

CSCS


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INTRODUCTIONINTRODUCTION

When a thing caeses to be a matter of controversy, it caeses to be a matter

of interest.

In reviewing past and present concepts and treatment modalities that areavailable, it becomes evident that there are no completely accepted

principles and techniques.

On this note, I would like to present my topic for seminar:

CONTROVERSIES IN PERIODONTICS.


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.

VIRAL BACTERIAL INTERACTIONS IN PERIODONTITISVIRAL BACTERIAL INTERACTIONS IN PERIODONTITIS

Recent studies have demonstrated various human viruses, especially cytomegalo

viruses and Epstein Barr Viruses type 1, seem to play a part in pathogenesis of

human periodontitis.

Parra and Slotes reported that HCMV was present in 60 % of patients and EBV- IN30%. Slots examined frequency of HCMV, EBV-2 and herpes simplex Viruses in

subgingival samples.

They reported 89% of samples yielded atleast one of three test viruses from deep

periodontal pockets and 56% yielded from shallow periodontal pockets


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Dual virus infection seems to be particularly pathogenic and they may

accentuate bacterial virulence factor.

HCMV resides in monocytes, macrophages, and T cells and EBV in B

cells, which has the potential to impair major defense mechanism of the

periodontium.

Tiny et al. reported that high rate of active HCMV infection in earlylocalized aggressive periodontitis.

They suggested that puberty is an important for HCMV and EBV primary

infection or reinfection.

Puberty related perturbation of immune system


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CMV has been shown to lead decreased Polymorphonuclear Leukocytechemotaxis, phagocytosis, oxidative burst and intracellular killing capacity and it

may increase the human susceptibility to bacterial infection.

HCMV infection of monocytes \ macrophage can induce prostaglandin E

2 production that may result in increased bone resorption and suppressed T

lymphocyte function.Mac Donald et al. emphasize the possible detrimental role of HCMV and EBV-1 in

periodontal repair.

Bacterial infection and other condition that promote diapedesis of

inflammatory cells in a tissue would increase possibility of initiating an HMCV

infection of the tissue.


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Contreras et al. in 1999 conducted a study to examine relation ship betweensubgingival herpes virus and periodontal disease and periodontopathogenic

bacteria

The study confirmed positive relationship between subgingival EBV-1, HCMV and

mixed herpes viral infections and clinical severity of periodontitis.

Viral infection promote subgingival pathogenic bacterial infection than vice versa.

Neutrophil dysfunction may serve to potentiate over growth and virulence of P

gingivalis and othermicrobes.


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WIDTH OF THE KERATINIZED GINGIVAWIDTH OF THE KERATINIZED GINGIVA

Attached gingiva is firm, resilient and tightly bound to underlying

periosteum of alveolar bone.

Distance between mucogingival junction and projection on external surface

of the bottom of the gingival sulcus

Keratinized gingiva includes marginal gingiva also.

No standard width of keratinized gingiva has been established.

It may be necessary to increase zone of healthy tissue if it is subjected to

trauma of the prosthetic treatment.


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For many years the presence of adequate zone of gingiva was considered

critical for maintenance of marginal tissue health and for prevention of

continues loss of connective tissue attachment.

Narrow zone of gingiva --

1) was in sufficient to protect periodontium from injury caused by frictional forcesencountered during mastication and to dissipate the pull on the gingival

margin created by muscles of adjacent alveolar mucosa.

2) it will favor sub gingival plaque formation

3) it will also favor attachment loss and soft tissue recession


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.

Goldman and Cohen outlined a tissue barrier conceptGoldman and Cohen outlined a tissue barrier concept

Dense collagenous band of connective tissue retards or obstructs the spread of

inflammation better than does the loose fiber arrangement of the alveolar

mucosa.

Limits recession as result of inflammation

This view is indirectly supported by findings of Kennedy et al.after recall

evaluations of u patients from their 6 years longitudinal study of free

autogenous gingival grafts

ADEQUATE WIDTH OF GINGIVAADEQUATE WIDTH OF GINGIVA

Some authors suggested that less than 1 mm.

Apicocoronal height ought to exceed 3 mm

Third category of authors stated that adequate zone of gingiva is any dimension ofgingiva which ---1) is compatible with gingival health or 2) prevents retraction of gingival

margin during movements of the alveolar mucosa.


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Lang and Loe conducted a study to evaluate the significance of the gingival zone.

The results showed that despite of the fact that tooth surfaces were free from

plaque, all sites with less than 2 mm exhibited persisting clinical signs ofinflammation..

In contrast teeth possessing least attached tissue s (cuspid and bicuspids) are least

involved periodontally as compared to molars.

Incidence of disease is greater on palatal and lingual surfaces of molars where

amount of keratinized tissue is greatest

Wenstrom and Lindhe have shown that a free gingival unit supported by a loosely

attached alveolar mucosa is not more susceptible to inflammation than a free gingival

unit that is supported by a wide zone of attached gingiva.

.


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Miyasato et al. (1997) ceased oral hygiene for a period of 25 days andfound no difference in development of clinical signs of gingivalinflammation between areas with minimal and those with appreciable

width of gingiva.

Dorfman et al. examined 96 patients with bilateral side facial toothsurfaces exhibiting minimal keratinzed tissues, which has been treatedwith free gingival graft on one side and un treated control on other side.

Width of keratinized gingiva on grafted site was increased to 4mmfollowing the treatment.

The attachment level at grafted sites and control remained unchangedthrough out the years.

Thus narrow zone of gingiva has the same resistance to continuesattachment loss as wider zone of gingiva.


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TRAUMA FROM OCCLUSIONTRAUMA FROM OCCLUSION.

What is occlusal trauma?

The international workshop forclassification of periodontal disease andconditions in1999.

Occlusal Trauma - It is injury resulting in tissue changes within attachment

apparatus as a result of occlusal forces.

Primary Occlusal Trauma Injury resulting in tissue changes from excessive occlusal

forces applied to a tooth or teeth with normal support.

Secondary trauma from occlusion Injury resulting in tissue changes from normal or

excessive occlusal forces applied to a tooth or teeth with reduced support.


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Several early authors felt that occlusal forces were the initiating factor in

periodontal disease and led to ongoing progression of periodontal lesion.

In an attempt to demonstrate this relationship several animal studies on

sheep and monkeys were conducted

Later some investigators state that traumatic occlusion causes changes

in attachment apparatus without involving gingival unit.

They postulated that change in attachment apparatus is mainly due to reduced

blood supply to periodontal ligament


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Orban and Weinmann in 1933 using human autopsymaterial evaluated .They concluded that there was no relation ship between excessive occlusal force

and periodontal destruction.

Instead they suggested that gingival inflammation extending in to supporting bone

was the cause of periodontal destruction

During the same time Glickman and co workers published studies.

These studies demonstrated a phenomenon described as an altered pathway ofdestruction when an excessive occlusal force was present.

Change in orientation of gingival and periodontal fibers

Co destruction.

Vertical osseous defects

Based on this observation, use of occlusal adjustment was advocated as part of the

treatment of existing periodontal disease,

Occlusal adjustment to prevent periodontitis was not advocated


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Waertaug evaluated large number of human autopsy specimens to determinerelationship of morphology of osseous defect and excessive occlusal forces.

No relation between excessive occlusal force and vertical bone loss.

Polson and Lindhe conducted studies to evaluate effect of plaque and excessiveocclusal forces in animal models.

These studies agreed removal of plaque and control of inflammation would stopprogression of periodontal disease whether or not excessive occlusal forces are

present.

Meitner reported when squirrel monkeys was subjected to repeated mechanicalinjury in combination with marginal periodontitis, the connective tissue loss wasnot greater than that of specimen in which periodontitis alone was induced.

Thus these appeared to be no co destructive effect on connective tissueattachment.

.


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PROBLEM IN RELATING FINDING FROM ANIMALPROBLEM IN RELATING FINDING FROM ANIMAL

RESEARCH TO THE HUMAN DENTITIONRESEARCH TO THE HUMAN DENTITION

An ideal model on which to study occlusion is not yet to be found.

If a high crown on tooth of a dog or monkey, the tooth will intrude andrecognize a new position while human tooth gets progressively

mobile.Parafunctional habit is a major factor in human occlusal trauma,

monkeys and dogs not known to have such persistent habits

Periodontal disease naturally occurs in humans.

In the animals models the lesion of periodontal is induced artificially.

With treatment these artificially treated lesion repair more predictablythan naturally occurring lesions


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PERIODONTAL ENDODONTIC CONTROVERSYPERIODONTAL ENDODONTIC CONTROVERSY

Two questions have been raised and continue to be matters of dispute.

1) Is periodontal disease a cause of pulpal necrosis?

2) Can a pulpless tooth be cause of periodontal disease?


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The effect of periodontal disease andThe effect of periodontal disease and

procedures on the dental pulpprocedures on the dental pulp


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Periodontal diseasesPeriodontal diseases

Recent publications have suggested that periodontal disease is a direct

cause of Pulpal atrophy and necrosis.

The pathways for communication and therefore for the extension of

disease from a periodontal pocket to pulp are through patent dentinal

tubules, lateral canals, and apical foramina.

Many histological and clinical studies suggest, however, that such

relationships rarely, if ever, result in pulp necrosis.


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Kirkham examined 100 periodontally involved teeth and found only 2% had

lateral canals located in a periodontal pocket.

Tagger & Smukler removed roots from molar teeth so extensively involved

with periodontal disease that root amputation was required, and found that

none of the resected roots showed inflammatory changes.

Haskell et al also removed roots from maxillary molars with periodontal

involvement and found no inflammatory cells or very few inflammatory cells

present in the pulps of the periodontally involved resected roots.


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Czarnecki & Schilder performed a histological study of intact, caries freeteeth and compared the pulp of teeth, which had periodontal disease.

The pulp of the periodontally involved teeth were all histologically similar tocaries free teeth .

Teeth with extensive decay or extensive restortations showed evidence ofpulpal pathosis.

Ross & Thompson evaluated the progress of 100 patients with maxillary molarfurcation involvement over a period of 524 years.

Of the 387 maxillary molars, 79% had at least 50% or less bone supportaround one root prior to periodontal treatment.

Only 4% required root canal treatment subsequent to periodontal therapy. Nonewere ascribed to the effects of advanced periodontal disease in pulp.


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Jaoui et al. studied patients with advanced periodontal disease for 514

years after completion of active periodontal treatment .

Of the 571 teeth that did not have root canal treatment at time of completion

of periodontal treatment, only one tooth required root canal treatment over

the 5 to 14 year recall period.

Pulpal insult through patent dentinal tubules or the occasional exposed

lateral canal have relatively insignificant effect on the ability of the dental

pulp tissue to survive.


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Periodontal proceduresPeriodontal procedures

The clinical research studies by Ross Thompson, Bergenholtz , Nyman

and Jaoui et al evaluated patients who presented with advancedperiodontal disease, received periodontal treatment.

They received follow up maintenance for periods ranging from 4 to 24years. There were 1,623 teeth in the combined studies

Four percent required root canal treatment subsequent to periodontaltreatment, and follow up periodontal care.

Cause of pulp necrosis was mainly due to pulpal exposure.

Extension of periodontal disease to involve the root apices is also citedas a reason for root canal treatment


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In summary dental pulp is capable of surviving significant insults and

that the effect of periodontal disease as well as periodontal treatment is

on the dental pulp is negligible.

The weight of evidence in literature shows that clinical significance of

the relationship between periodontal disease and dental pulp has been

exaggerated in historical and much of the current periodontal

endodontic literature


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Effect of endodontically involved teeth on periodontalEffect of endodontically involved teeth on periodontal

health and healinghealth and healing

. Only in recent years the potential effect of a tooth with a necrotic pulp ora tooth that had root canal treatment was considered as a risk factor in

the initiation of periodontal disease.

Pulpless tooth with a periapical lesion promotes the initiation of

periodontal pocket formation and interfere with healing of periodontal

lesion after periodontal treatment.

Jansson et al. state that teeth teeth with periapical lesion had lost more

proximal bone .

0.19 mm\ year vs 0.06mm\ year for teeth with no periapical lesion orwhere there is evidence of reduction in lesion size.


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Sanders et el. reported in 1983 that after the use of freeze dried bone

allografts 65% of teeth that did not have root canal treatment showed

complete or greater than 50% bone fill in periodontal osseous defects.

While only 33% of teeth which had root canal treatment prior to

periodontal surgical procedure had complete or greater 50% bone fill.


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ROLE OF LYMPHOCYTES IN PERIODONTITISROLE OF LYMPHOCYTES IN PERIODONTITIS

Inflammatory cells, predominantly lymphoid cells and macrophagesthought to be engaged in controlling bacterial challenge.

Participation of these cells in a major way in process of tissue

destruction had not yet been conceived.

In 1970 antibodies to cell surface markers became available which

allowed sub categorization of T lymphocytes in to two major

subsetsCD4and

CD

8.

. CD4 molecules serves as a co receptor for major histocompatibilityclass two molecules on antigen presenting cells.

CD8 molecule is a co receptor for MHC class one molecules of the

target cells.


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Phenotypic AnalysisPhenotypic Analysis

Phenotypic analysis shows that there are no numerical abnormalities of

T helper cells or major cells.

There may be altered ratios of CD4 to CD8 in periodontal lesions of

aggressive periodontitis patients


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Functional studiesFunctional studies

T and B-lymphocytes are present in lesions of early onset periodontitis

patients.

Two accepted activities of the lymphocytes are.

1) They may provide protection against host from infectious agents.

2) they contribute to host tissue damage.

B cells and their linear descendents secrete immunoglobulins (IgG) that

may inactivate bacterial toxins, prevent bacterial adherence and

promote bacterial phagocytosis by polymorphonuclear leukocytes.


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Juvenile periodontitis patients frequently have elevated levels of serumIgG antibodies against AA antigens.

But still there has been controversy that whether these antibodies wereprotective or not.

IgG2 antibodies are the predominant sub class presented.

IgG2 antibodies are not been thought to be effective direct opsonins, oractivators of direct classical pathway.

IgG2 antibodies can kill AA only when neutrophil has the properallotypic form of fc receptor.

Abnormal lymphocyte function in early onset periodontitis asmanifested by lower than normal levels of non stimulated DNAsynthesis in cultured peripheral blood mononuclear cells.

This reaction has been called autologous mixed lymphocyte function(AMLR )


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In some of the studies of periodontal disease patient AMLR returned to

normal after periodontal treatment.

It is not known how diminished AMLR relates to early onset

periodontitis.It has been suggested that reduced AMLR relate to

improper regulation of B cell responses.

In 1974 Langer et al. reported that peripheral blood lymphocyte from juvenile periodontitis patients exhibited reduced blastogenic response

to dental plaque and gram ve bacteria.

Several other studies following this early reports found that

lymphocytes from periodontitis patients exhibited more exacerbated

than normal blastogenic response to mitogens and bacterial antigens.

This phenomenon remains with no strong scientific evidence although it

may be related to reduce AMLR via reduced population of suppressor

inducer T cells.


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ROOT - CONDITIONINGROOT - CONDITIONING

Exposed root surface as result of periodontitis has undergonesubstantial alteration and may no longer serve as an appropriatesubstrate for cell attachment.

Loss of collagen fiber insertion, contamination of root surface bybacteria and alteration in mineral density.

Root surface also lack chemotactic stimuli for migration of cell capableof producing periodontal regeneration.

Apical migration of junctional epithelium along root surface over

connective tissue following surgical therapy also appear to inhibitregeneration


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Scaling and root planning is effective in removing bacterial deposits as wellas removing endotoxins from exposed root surface.

How ever it results in formation of smear layer is thought to serve as aphysical barrier between periodontal tissues and root surface and mayinhibit formation of new connective tissue attachment to root surface.

Root conditioning of these periodontally involved root surface will eliminate

cytotoxic materials, will dematerializes the planed root surface,will alsoexpose and enlarge opening of dentinal tubules and will dematerializes theinter tubular dentin.

Exposed collagen matrix of dentin is chemotactic for PMN, macrophageand fibroblasts.

It can also support the attachment and migration of fibroblast.

Root surface demineralization will also enhance healing


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HISTOLOGICAL AND CLINICAL SUTDIESHISTOLOGICAL AND CLINICAL SUTDIES

College of dentistry --Columbus asses the efficacy of root surface

biomodification through tetracycline citric acid or EDTA in patients with

chronic periodontitis.

They included all the studies evaluating histological and clinical effects

of citric acid, tetracycline and EDTA.

They excluded studies evaluating effects of extra cellular matrix protein,

enamel matrix protein or growth factors applied to root surface.


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Main resultsMain results

Thirty-four studies incorporating total patient population of 575 wereanalyzed, 26 for citric acid, 5 for tetracycline and 3 EDTA treatment.

Four of eight human histological studies represents regeneration with

use of citric acid and only 1 of 18 clinical studies reported attachmentgain.

Of 5 studies using tetracycline, 1 histological study and 1 clinical studyreported attachment gain.

No regeneration was reported in the 3 studies evaluating use of EDTA.


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Reviewers conclusionReviewers conclusion

Evidence to data suggests that use of citric acid, tetracycline and EDTAto modify root surface provides no benefit of clinical significance to

regeneration in patients with chronic periodontitis


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Root conditioning delays wound healing?Root conditioningdelays wound healing?

Selvig et al. examined wound healing in experimental fenestration

defects following conditioning of defects walls with either saline or citric

acid.

Following elevation of mucoperiosteal flaps, fenestral defects where

covered with polytetrafluroethylene membrane.

Post surgically after 14 days healing appears to be delayed in citric

acid treated site as compared to the control.


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RESTORATION OR IMPLANT PLACEMENT: ARESTORATION OR IMPLANT PLACEMENT: A

growing treatment planning quandarygrowing treatment planning quandary

Regardless of the implant system, the placement and functional success of

endosseous implants is greater than 90%.

Is a tooth with questionable prognosis restored or intervened with dental

implant?

Should a tooth with large post and core restoration and failing endodontic

procedure is re treated conventionally or should it be extracted?

Is it better to replace such a tooth with an implant?

If the implants fail to integrate or if restoration is an esthetic failure, would it

have been better to retain the tooth?

Answering such questions is a challenge for clinicians. Clinical and economic

factors should be considered in making such decisions.


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Clinical factorsClinical factors

The heavily restored toothThe heavily restored tooth

These teeth may have been restored multiple times, have minimal

external coronal dentin for an adequate restorative ferrule.

The post space can be so large that internal dentinal walls of the

preparations are too thin.

If greater force is to be exerted on a tooth, increase in the resistance

form should be made.

Crown lengthening can increase resistance but at the expense of

removing bone of adjacent teeth.

Orthodontic extrusion can also be considered but extrusion adds both

additional financial cost and increased time to treatment.


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Immediate implant placement along with single stage surgical placement

limits number of procedures.

Before the acceptance of sinus augmentation procedures, the choice mighthave been to retain teeth with root resective and endodontic retreatment procedures.

Previously it was thought that implants in posterior maxillae or mandiblewas less ideal.

.

Decision for implant placement may change if patient is a heavy smoker orif they are an uncontrolled diabetic, factors which could compromiseimplants


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The Furcation involvementThe Furcation involvement

Reducing attachment levels for crown lengthening or for root resective

procedures may have a negative long-term impact.

Periodontally involved molars are the most common teeth lost.

Furcation and concavities associated with them make them difficult to

treat.

Resecting roots can improve debridement acess but literature differs asto success of root amputations or hemisections.

Reasons for failures were current decay, endodontic failure,root

fractures and less commonly, recurrent periodontal dis

Resection may require osseous removal to the adjacent teeth, as

crown lengthening does. If osteoplasty \ ostectomy is not performed then plaque retentive

areas are created


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HemisectionHemisection

Hemisection, the length of root trunk affects how much bone is

removed to create positive osseous architecture.

To create a positive osseous architecture a large amount of bone must

be removed on remaining root and adjacent tooth..

If the patients anatomy requires sinus augmentation, then clinician

may reconsider treating tooth with root resection.


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Difficult anterior esthetic casesDifficult anterior esthetic cases

The use of dental implants to replace anterior teeth is one of the lastareas to gain acceptance by dental profession.

The greatest benefit is avoidance of unnecessary preparations of non-restored teeth adjacent to an implant.

Professional acceptance of implants in esthetic zone has increased

because they are

Better pre-surgical planning guidelines.

More option in diameter of implants fixtures.

Great variety of abutments.

Better techniques for preparing edentulous ridge.

Better prosthetic techniques to produce a high esthetic final restoration.


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ECONOMIC FACTORSECONOMIC FACTORS

Clinician as well as patients many times elects best economic option

than best treatment option.

Some still argue that the long-term success rates of implants are not

high enough and that questionable teeth should be maintained until

they become hopeless.


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Hand versus Ultrasonic InstrumentationHand versus Ultrasonic Instrumentation

Partial removal of cementum became established as a therapeutic

procedure over one century ago.

Mergenhen and Hampp were the first to demonstrate that plaque

related gram-negative bacteria produce the complex lipo-polysachride

endotoxins described by Boe in 1941

Aleo and De Renzius scientifically proved the significance of root

cementum bound endotoxin removal in periodontally diseased teeth.

In 1974 they showed that cementum of these involved teeth contains

endotoxins and also found that this lipo-polysachride is toxic to cells invitro.


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ComparisonComparison

Many investigators have compared hand and ultrasonicinstrumentation.

Nishimine and O Leary showed that root planning was more effectivethan ultra sonic scaling in removing endotoxins from periodontally

involved root surfaces.

Two investigations evaluated the smoothness of root surfaces at anulrtastructural level following hand and ultrasonic instrumentation.

One study reported a much smoother root following ultrasonic scaling.

The second study reported opposite results.

Luiggi and Gian conducted a study to compare efficacy of ultrasonicand hand instrumentation.

They found no significant differences between fibroblast growth on

periodontally involved root surfaces treated with hand instruments andwith ultra sonic scalers.


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Several studies reported on an increased efficiency of subgingivalinstrumentation with both sonic and ultra sonic scalers, since manual

instrumentation takes longer to achieve the same clinical results(Dargoo 1992,Copulos et al. 1993).

Power driven instruments have been shown to be superior in treatmentof class 2 and class 3 furcations (Leon & Vogel 1987).

Development of heat at scaler tip when water-cooling is not sufficient.This increased temperature may cause injury to pulpal and periodontaltissues.

Another draw back is formation of pathogenic bacterial aerosols andthe reduced tactile sensation in comparison to hand instruments.


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NONSURGICAL ANDNONSURGICAL AND

SURGICAL PERIODONTALSURGICAL PERIODONTAL

THERAPYTHERAPY


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NONSURGICALNONSURGICAL

PERIODONTAL THERAPYPERIODONTAL THERAPY

Conventional nonsurgical periodontal therapy consists of mechanical supra andsubgingival tooth debridement

Reducing the bacterial load and altering the microbial composition towards aflora more associated with health,which in turn result in lower levels of

inflammation and relative stability in periodontal attachment levels.

In the past, endotoxin or lipopolysacchairde derived from cells of gram-negativebacteria was though to be so firmly attached to the root surface.

More recent studies on extracted teeth indicate that endotoxins are superficiallybound and can be removed by such means as brushing.

Thus systematic root planing to remove cementum does not seem warranted.


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Furcation opening is often less than 1 mm, too small to be effectivelyreached with relatively larger curettes.

Most of the new ultrasonic tips are approximately 0.50mm in diameter,which may favor ultrasonics as the instruments of choice for furcationsites.

One study on instrumentation of furcations with and without surgicalaccess indicates that no major differences were observed between useof curettes or ultrasocics in the closed treatment groups and in widefurcations.


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PERIODONTAL SURGERYPERIODONTAL SURGERY

The following have been proposed as the aims of periodontal surgery:

Accessibility to previously in accessible root surfaces.

Production of healthy dento-gingival junction that would enable thepatient to practice a high level of plaque removal.

Reduction of probing depths to allow - a) effectively deliveredmaintenance and home care and b) the monitoring and or diagnosis ofrecurrent inflammation and progressive periodontal disease.


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COMPARISON OF SURGICAL AND NONSURGICALCOMPARISON OF SURGICAL AND NONSURGICAL

TREATMENT MODALITIESTREATMENT MODALITIES

An early study employing a split-mouth design was that of knowles etal.

. Three modalities were tested sub-gingival curettage, modified Widmanflap surgery and pocket elimination surgery

After evaluation for eight years all techniques resulted in favorable

changes in the means of the clinical parameters measured The surgical techniques resulted in slightly more pocket reduction in

deep pockets. The modified Widman flap resulted in the greatest clinical attachment

gain.

In studies comparing the effects of root planing and modified Widmanflap surgery over 6 years of observation,.

The modified Widman flap resulted in more pocket reduction in initiallydeep pockets, although mean attachment levels were similar.

In summary following points may be deducedIn summary

following points may be deduced


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In summary, following points may be deducedIn summary, following points may be deduced

from available literature.from available literature.

Both non-surgical and surgical therapies have been shown to resultin similar mean improvements of clinical scores.

Data for the possible adjunctive effect of surgical procedures onpatients/sites unresponsive to initial therapy are scarce.

Data for the possible adjunctive effect of surgical procedures onpatients believed to be at high risk to ongoing attachment loss arescarce.

Other than studies on regenerative techniques data for thecomparable effects of different surgical modalities on furcation areas

are also scarce.

Data for long-term outcome measures, such as tooth loss andquality of life issues, are scarce.


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PERIODONTITIS PERIODONTITIS

SYSTEMIC DISEASESYSTEMIC DISEASE

ASSOCIATIONS IN THEASSOCIATIONS IN THE

PRESENCE OF SMOKING PRESENCE OF SMOKING CAUSAL ORCAUSAL OR

COINCIDENTAL?COINCIDENTAL?


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No Current issue in periodontal research is more visible or controversialthan the relationship between periodontitis and systemic diseases.

Four lines of evidence suggests that the observed periodontitis-systemicdisease associations are in part a result of confounding by smoking

First, no periodontitis-systemic disease associations have been identifiedamong neversmokers.

Second, periodontitis and smoking mimic one another with respect to thetypes of diseases with which they are associated (e.g. lung cancer andParkinsons disease).

Third, only studies with inadequate adjustment for smoking report

significant periodontitis-systemic disease associations.

Lastly, elimination of dental infection, unlike smoking cessation, does notreduce coronary heart disease risk.


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Smoking, the epidemoiologists perspectiveSmoking, the epidemoiologists perspective

Individuals with periodontitis are more likely to be current or pastcigarette smokers.

When individuals with and without periodontitis are compared it is to beexpected that individuals with periodonititis will have more smoking-related diseases, such as coronary heart disease, lung cancer, low-birth weight babies etc.,..

Statistical adjustment of control for confounding is possible.

Such statistical adjustment can be used to eliminate some but not allof the bias caused by the smokers.


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The imperfect smoking questionnaires,the inability to ask questions or otherwise

obtain information on important characteristics of smoking, all make it virtually

impossible to have perfect statistical adjustment for smoking.

Wherever past or current smokers are included in the analyses, biased

periodontitis systematic disease associations will be reported.

Therefore, primary analyses should be limited to healthy never-smokers both

because smoking is such a strong risk factor and because the magnitude of

smoking cannot be well measured.


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Effect of smoking on Periodontitis cannot beEffect of smoking on Periodontitis cannot be

distinguished from the effect of smoking ondistinguished from the effect of smoking on

systemic diseasessystemic diseases Periodontitis-systemic disease associations have not been identified

among never-smokers.

Periodontitis and smoking are associated with similar health risks.

Conflicting study results can be explained in terms of statisticaladjustment for tobacco smoking.

Dental infection elimination through complete tooth removal, unlikesmoking cessation, does not reduce health risks.


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Periodontitis and chronic obstructivePeriodontitis and chronic obstructive

pulmonary disease (COPD)pulmonary disease (COPD)

Among past and current smokers, periodontitis significantly increased

the risk for COPD.

When the analysis included past, current, and never smokers with

adjustment for reported smoking dose and duration, the HR for COPDdecreased by 7%.

Finally, when the analysis was limited to never-smokers, periodontitis

was associated with a small and insignificant increased risk for COPD.


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Periodontitis and lung cancerPeriodontitis and lung cancer

Among past and current smokers, periodontitis significantly increasedthe risk for lung cancer

When the analysis included never, past, or current smokers, withadjustment for smoking the HR for lung cancer associated withperiodontitis decreased by 49%.

When the analysis was limited to never-smokers, the oppositeassociation was present.

Periodontitis was associated with a decreased risk for lung cancer, notan increased risk.


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P i d titi d h t di (CHD)P i d titi d h

t di (CHD)


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Periodontitis and coronary heart disease (CHD)Periodontitis and coronary heart disease (CHD)

Among past and current smokers, periodontitis significantly increased the riskfor CHD by 26%.

Among past, current and never-smokers the HR for CHD associated withperiodontitis was 1.13.

Finally, when the analysis was limited to never-smokers, the HR for CHDassociated with periodontitis became insignificant).

Imperfect adjustment for smoking history is inducing associations betweenperiodontitis and smoking related diseases.


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There is also hope that periodontal treatments can reverse anincreased CHD risk..

Findings from the same cohort study indicated that completeelimination of all dental infections by extraction does not decreaseCHD risk..

Then why would an incomplete, imperfect and reversible decreasing ofthe bacterial load by means of periodontal treatments decrease CHDrisk?

Some have offered the explanation that the risk, once established, isnot reversible and therefore primary periodontitis prevention trialsrather than secondary prevention should be initiated.


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Dental infection elimination through completeDental infection elimination through

complete


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Dental infection elimination through completeDental infection elimination through complete

tooth removal does not reduce health riskstooth removal does not reduce health risks

There is certainly hope that secondary prevention of CHD events canoccur through periodontal treatment.

Current epidemiological evidence does not support the hope thatperiodontitis plays a role in secondary heart disease prevention.

A cohort study in the US population suggests that periodontitis doesnot increase the risk for secondary heart disease events.

Individuals with periodontitis and pre-existing heart disease were foundto be at the same risk for developing a secondary heart disease eventas the individuals with pre-existing heart disease but withoutperiodontitis.


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There is also hope that periodontal treatments can reverse anincreased CHD risk..

Findings from the same cohort study indicated that a definitive,irreversible, and complete elimination of all dental infections by

extraction does not decrease CHD risk.

Then how incomplete, imperfect and reversible decreasing of thebacterial load by means of periodontal treatments decrease CHD risk?

Some have offered the explanation that the risk, once established, isnot reversible and therefore primary periodontitis prevention trialsrather than secondary prevention should be initiated.


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CONCLUSIONCONCLUSION


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THANK YOUTHANK YOU

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