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IATROGENIC
FACTORS AFFECTING
PERIODONTIUM
Hrishi T S
INTRODUCTION
Careless therapeutic procedures ,Injudicious use of
instruments &chemicals, Improper treatment planning and negligence
cause traumatic injuries to periodontium
supporting tissues must be always maintained in a state of health for
proper function
Injuries induced by the dentist can severly impair the periodontium
and other oral structures leading to morbidity of patient
SO the dentist should inculcate thorough knowledge and
expertise to “do no harm” to the patient
Iatrogenic- means…
iatros • physician
gennan • To produce
IATROGENIC DISEASE
Disease that has been induced by the physicians' activity,
manner, or therapy, and this term is usually used for an
infection or other complications of treatment.
IATROGENIC FACTORS IN DENTISTRY
Inadequate dental procedures that contribute to the
deterioration of the periodontal tissues.
Causative factors
Restorative
Endodontic
Prosthodontic
Orthodontic
Exodontia
Periodontal
Restorative factors
Marginal periodontium Fields of Restorative Dentistry &
Periodontics overlap
Restorative Factors
♣Violation of Biologic Width
♣Morphologic Features of Restorations
♣Restorative materials
♣Direct injury to the Periodontium
Biologic width and its Violation
The biologic width is
defined as the dimension of
the soft tissue, which is
attached to the portion of
the tooth coronal to the
crest of the alveolar bone.
tissue occupying the area
between the base of the
gingival sulcus and alveolar
crest
† Gargiulo et al. (1961)
287 individual teeth from 30 autopsy specimens
Definite proportional relationship between the alveolar crest, the
connective tissue attachment, the epithelial attachment, and the
sulcus depth
Mean dimensions:
sulcus depth - 0.69mm,
epithelial attachment -0.97mm,
connective tissue attachment -1.07mm.
biologic width- 2.04mm
Vacek et al. (1994)
Reported similar biologic width
dimensions
Observed mean measurements
• 1.34mm for sulcus depth
• 1.14 for epithelial attachment,
• 0.77mm for connective tissue
attachment
biological width of 0.75- 4.3 mm
Biologic width evaluation
Radiographic – not diagnostic- due to superimposition
Sounding to bone
A minimum of 3mm was required from the restorative
margin to the alveolar crest to permit adequate healing
of periodontium following restoration of the tooth.
Ingber et al(1977)
This allows for adequate biological width when
restoration is placed 0.5 mm within gingival sulcus
VILOLATION OF BIOLOGIC
WIDTH
INFLAMMATION
BONE LOSSATTACHMENT
LOSS
periodontal pockets gingival recession
Violation of Biological Width
Unpredictable bone Loss
Gingival Recession
Body attempts to recreate the biological width
Persistence of gingivitis
Correction of Biologic Width Violations
Surgical Crown Lengthening to remove bone away from
the restorative margin
Orthodontic extrusion of tooth
Surgical crown lengthening
Gingivectomy
• adequate attached gingiva and more than 3mm of soft tissue coronal to the bone crest
Flap surgery +bone contouring
• Inadequate attached gingiva and less than 3mm of soft tissue.
• The bone removed by measuring distance of the biologic width + 0.5 mm as safety zone
Orthodontic extrusion
Low orthodontic extrusion forces
Tooth will erupt slowly bringing
the alveolar bone & gingival
tissue with it till
ideal level
Surgical correction of the bone
and gingival level
Rapid orthodontic extrusion
Tooth is erupted to desired amount in
several weeks
Supracrestal fibrotomy performed weekly
in an effort to prevent the bone and tissue
from following the tooth
The tooth is stabilized for 12 weeks
• unaesthetic
• Well tolerated
Supragingivalmargins
• Earlier thought to retain plaque
• Well polished restorations are well tolerated
Equigingivalmargins
• Not accessible for cleaning and polishing
• Placed far below can violate biologic width
Sub gingival margins
Margins of Restoration
Guidelines for placement of margins using sulcus depth as a
guide
Sulcus depth 1.5 mm or less – margins
0.5mm below the gingival crest
Sulcus depth more than 1.5mm-margins at
half the depth of the sulcus below tissue
crest
Sulcus depth greater than 2mm esp on facial
aspect- Gingivectomy performed to reduce
the depth to 1.5mm
Effect of subgingival margins
Large amount of plaque
More severe gingivitis
Greater loss of attachment & recession, Deeper pockets
Increase rate of GCF flow
(Waerhaug 1978, Silness 1980, Orkin 1987)
Subgingival zone is composed of the
• Margin of the restoration
• The luting material
• Prepared and unprepared tooth surface
Marginal roughness can contribute to plaque accumulation
sources
Improper marginal fit
Separation of the restoration margin and luting material
Dissolution and disintegration of the luting material
Subgingival margins typically have a gap of 20 to
40 μm between the margins of the restoration and
unprepared tooth
Colonization of this gap by bacterial plaque contributes to the
detrimental effect of margins placed in a subgingival
environment
Orkin et al. (1987) demonstrated that subgingival restorations
had a greater chance of bleeding and exhibiting gingival
recession than supragingival restorations.
Supragingival position of the crown margin was the most
favorable, whereas margins below the gingival margin
significantly compromised gingival health
Waerhaug (1978) stated that subgingival restorations are
plaque-retentive areas that are inaccessible to scaling
instruments
Stetler & Bissada (1987) -Teeth with subgingival
restorations and narrow zones of keratinized gingiva showed
significantly higher gingival index scores than teeth with
submarginal restorations with wide zones of keratinized
gingiva
Factors determining location of restorative margins:
esthetics
retentive factors
susceptibility to root caries, and
degree of gingival recession.
Prudent to place restorative margins supragingivally if :
Esthetic
increased retention form
preexisting margins
root caries
cervical abrasion
Root Sensitivity
Not a concern
MORPHOLOGIC
CHARACTERISTICS
Overhangs
An extension of restorative material beyond the
confines of a cavity preparation
RESTORATIVE OVER HANGS
Overhanging dental restorations a contributing
factor to gingivitis and possible periodontal
attachment loss
prevalence estimated at 25–76% for all
restored surfaces (Brunsvold & Lane1990)
overhanging restorations contribute to gingival inflammation
due to their retentive capacity for bacterial plaque
)
Jeffcoat and Howell (1980) demonstrated a link to
the severity of the overhang and the amount of
periodontal destruction
with overhangs, the flora changed from gingival
health to one of chronic periodontitis with
increase in black pigmented bacteriodes Lang et
al. (1983)
Highly significant association b/w bone loss and
overhanging restoration Hakkaranein & Ainamo 1997
Removal of overhangs permits more effective control of
plaque and reduction of inflammation and small increase in
bone height Jeffcoat & Howell ( 1980) )
Mechanism by which overhangs cause
periodontal destruction
promote the retention of plaque
complicate plaque control
Increase in the specific periodontal pathogens
Impinge on the interproximal embrasure space
Displacement of gingiva & violation of biologic width
overhanging restorations can be recontoured without replacing the restoration
should be considered a standard component of
nonsurgical treatment
Diamond burs Diamond strips
Prevention
Use of wedges and proper adaptation of matrix bands
Contour and Contacts
Undercontouring
Overcontouring plaque retentive no
self cleansing effect in ginival third
Overcontouring can occur in
• Interdental Areas
• Buccolingual Aspect
• Furcation Aspects
Overcontoured restoration forming a plaque trap
Interproximal contact areas are commonly
overcontoured
The proximal contacts determine
• Marginal ridge relationships
• Occlusal embrasure form
• Buccal and lingual embrasure form,
Marginal ridges of unequal height or of improper contour
€ Encourage food impaction and retention
€ Contribute to the breakdown of interdental
tissues
€ Subsequently to interproximal bone loss
Overcontouring leads to
Collection of debris
Inflammation
Hyperplasia
Engorgement of marginal gingiva
Decreased keratinization
Deterioration of gingival fibers
greater the amount of facial and lingual bulge of an
artificial crown, the more the plaque retained at the
cervical margin. Yuodelis et al. (1973)
buccal and lingual crown contours should be ‘‘flat’’,
not ‘‘fat
furcation areas should be ‘‘fluted’’ or ‘‘barreled out’
Becker & Kaldahl (1981)
Furcation Region
Overcontouring of exposed furcation region
Formation of a horizontal triangular region by roots & cervical bulge
Plaque accumulation
Periodontal breakdown
CONTACTS
loose or open proximal contacts –contributing factors to
periodontal pocket formation
greater food impaction at sites with open or loose
contacts
Literature proposes conflicting views
No difference in periodontal breakdown at sites with
deficient proximal contacts compared to satisfactory
sites Kepic & O’Leary (1978) Hancock et al (1980)
Occlusal view of normal buccolingual
width and position of interdental contact
Excessively wide contacts obliterates
interdental embrasure
Hyperplastic bulging of interdental
papilla
Interdental contacts if placed too high
occlusally
Eliminate the marginal ridge & reduce
sufficient area of contact
Food Impaction
Buccal view of excessive
occlusogingival extent of
interdental contact, which also
obliterates essential interdental
embrasure
normal position and size of
proximal contact creating a slight
col
Interdental view of abnormally widened
proximal contact,
Resulting in exaggerated col formation
that is subject to breakdown.
Broadened proximal contacts constrict both
occlusal and interdental embrasures.
Difficult to clean the interdental area
Characteristic changes of interdental tissue
• Facial and lingual hyperplasia of interdental
papilla
• Exaggerated col formation
• Microbial invasion
• Inflammation and edema
• Osseous involvement
Excessively narrow interdental & lack of contact
food impaction and retention tooth drifting
marginal ridge discrepancy and bone loss
Occlusal Morphology of
Restoration
Increased Buccolingual Width of Occlusal Table
More axial stress transmitted to
periodontium with wide occlusal table
than narrow
Greater incidence of cross- arch & cross
tooth balancing interferences during
lateral excursive forces
• Obliteration of natural sluiceways
• Improper passage of food from the occlusaltable
• Food being forced into the contact area
Tooth with high filling , painful
Patient forced to acquire a diff. relationship of maxilla to mandible
Puts many other teeth into traumatic functional relationship
TMJ problems
HIGH POINTS
Overcarving of occlusal anatomy to remove centric
holding areas
erupt in new occlusalrelationship
Traumatic to the periodontium
during functional and parafunctional
excursive movements
CARVING
Materialrestorative materials are not themselves injurious
exception - self-curing acrylics
surface of restorations should be as smooth as
possible to limit plaque accumulation
Crown & bridge cements cause
irritation
Non- precious alloys Inflammatory gingival response
Pierce LH, GoodkinRJ, 1989
Nickel – allergic reaction in 9% of people
Case of alveolar bone loss after the placement of crowns with a
high nickel content has been reported( Bruce GJ, Hall WB 1995)
Surface Roughness
☻Tissue respond more to surface roughness than
composition of material
☻Roughness of intra-oral surfaces increase in plaque
retention .They protect bacteria against shear forces
☻all restorative materials placed in the gingival
environment should have the highest possible degree of
polish.
Roughness affects the
Initial Adhesion & Colonisation
Bacteria protected from
natural removal forces & oral hygiene
measures
Survive longer
-Reversible to irreversible attachment
Rough surfaces ↑area for adhesion by 2-3 times
ROUGHNESS AND MICROBIAL COLONIZATION
Rough surfaces accumulate and retain more plaque,
It is less obvious when optimal oral hygiene
Increased proportion of motile organisms and spirochetes
Inflamed periodontium,
↑ bleeding index, ↑GCF
Procedures that Increase Roughness
• Polishing paste on restorative material
• Application of fluoride gel on porcelain
• Application of fluoride gel (pH<5) or gels
containing hydrofluoric acid on titanium implants
• Air powder abrasive systems on all materials
Subgingival Debris
Subgingival debris can be left during-
Use of retraction cord
Impression material
Provisional material
Cement
Examining the sulcus with explorer, remove the foreign
bodies
INJURY TO THE PERIODONTIUM BY
RESTORATIVE PROCEDURES
Application of Rubber Dam and Matrix
Placed too subgingivally Stripping of junctional epithelium
and gingival connective tissue
attachment
Placed for too long Ischemia to the degree that
sloughing of tissue and subsequent
gingival recession
Cavity and Crown
Preparation
Laceration of the
gingival margin
Inflammatory gingival margins
Injury in the region of
inadequate attached gingiva
GINGIVAL
RECESSION
Placing the Matrix/ Wedges
Placement of matrix and wedges without care may
injure the PDL.
A matrix which is not rigid and properly contoured
may not prevent intracrevicular overhangs.
Injudicious separation beyond the width of the
periodontal ligament may injure the periodontium
Improper placement of matrix band and wedge
result in poor contour
Food lodgment and plaque accumulation
Impressions retraction cords are used to displace the free
gingival tissues
. May cause damage to subgingival tissue.
(Usually reversible)
injudicious use of gingival-retraction techniques
can injure the soft tissues and cause permanent
alterations, such as recession.
Dry retraction cords cause stripping of junctional & sulcular
epithelium while removal
Retraction cords impregnated with chemicals- chemical burns
Chemical burn Retraction cord soaked with ferric sulfate,
• Electrosurgical retraction recession & loss
of attachment
• Not indicated in regions of inflammation or of
extremely thin gingival tissue
misuse can cause extensive damage
Gingival recession and sequestration of
bone after electrosurgery
Electrosurgical burn on the palatal aspect of
the maxillary left canine
Retained elastic impression materials, within periodontal
tissues after removing impression can lead to massive
loss of attachments
Provisional RestorationsIf made in haste or without consideration - permanent
damage to periodontium
Critical areas include
The marginal fit
The contour
The surface finish
Overextended Temporary Crowns
• Gingival alterations in interdental, facial and lingual marginal region
• Hyperplasia or recession if attachment is injured severely
UnderextendedTemporary Crowns
• Not as serious as overextension
• Hypersensitivity, interfering with adequate oral hygiene measures
Poor proximal-contact relationships
• Food impaction and retention
• Drifting of the approximating teeth
Rough or Porous Surface Finish
• Difficult to maintain good oral hygiene
• Plaque accumulation
• Inflammation
• Recession
ENDODONTIC PROCEDURES
Root perforations
Frequency - 3 to 10%
Artificial communication b/w root canal system and
supporting periodontium
Root perforations occur during
Access cavity preparation
Root canal preparation
Post space preparation
Location
Cervical
Midroot
Apical
Prognosis
₯Location of perforation- most imp
₯Time lapse b/w occurrence & treatment
₯Size of the perforation
Crestal root perforations - most susceptible to epithelial
migrations & rapid pocket formation
Perforations in furcation areas - because of
proximity to epithelial attachment-
secondary periodontal involvement
If the perforation is located close to the gingival
sulcus- periodontal pocket
Bacterial infection following perforation
Exacerbation of a preexisting periodontal lesion -development of
clinical symptoms similar to those of a periodontal
abscess
Down growth of epithelium, inflammation ,
bone resorption and necrosis can result
Obturation of defects with gutta-percha- poor seal and subsequent bacterial
inflammation of periodontal tissues
VERTICAL ROOT FRACTURES
CAUSES
• preparation of canal for post
• Increased compaction pressure during
obturation of root canal
• Improper selection of post
• Expansion of posts and pins due to
corrosion
DIAGNOSIS
Radiographs show typical ‘J shaped
‘radiolucency
Wide space adjacent to the obturated canal
Deep narrow isloated pocket depth
COMPLICATIONS
Inflammation due to plaque accumulation
abscess
Fistulas
Osseous defects
PROSTHODONTIC PROCEDURES
Prosthesis are susceptible for plaque formation
inflammatory tissue reactions of mucosa covering
alveolar ridge can occur in response to bridge pontics
Pontic Designs
• Pontic should have a occlusal surface that Stabilizes the
opposing teeth
• Allows for normal mastication
• Doesn't overload the abutment teeth
• Occlusal table need not be buccolingually narrower than
those of the abutment teeth.
Manner in which pontic is designed & adapted to
edentulous ridge determines health of the surrounding
tissues
Concavities on tissue surfaces plaque trap
bacterial accumulation inflammation of
adjacent tissues
Sanitary
Tissue surface 3 mm away from ridge
Ridge lap
Tissue surface straddles the ridge like a
saddle
Modified ridgelap
Tissue surface on facial side
concave
OVATE
Tissue surface is
convex- fits into
receptor site
RIDGE-LAP
-Least desirable periodontally
- Difficult plaque control
MODIFIED RIDGE- LAP
-More open lingual form
- Better access for hygiene
OVATE
-Ideal pontic design
- Easy to clean
- Esthetically satisfactory
Pontic design
SANITARY
-Easiest access for
hygeine procedure
-Unesthetic form
Excessive contact of
pontic with ridge Causes initial
blanchingBone resorption
Scraping of edentulous cast for positive contact
Atrophy of underlying bone
Periodontal involvement of abutment teeth
Severely tilted abutments
Deep psuedopocket
on mesial aspect of such
teeth
periodontal breakdown
Removable Partial DentureRPD increased gingivitis, periodontitis & abutment
motility
FACTORS ATTRIBUTED TO PDL BREAKDOWN
Plaque Formation & oral hygiene
Coverage of marginal gingiva by parts of RPD
Occlusal forces transmitted to the remaining teeth & their
periodontal tissues by the prosthesis
Gingival health was adversely affected by RPD
Degree varied based on denture gingival relationship
Severe pathologic changes occurred in areas without
relief
Metallic bases elicited less response
Gingival responses to various types of removable partial dentures
(Bissad et al, 1974 )
Plaque formation and oral hygiene
Increase plaque accumulation on tooth surface in direct
contact with dentures & teeth in opposing arch.
the microbial composition of dental plaque
developing on fifteen abutment teeth
removable partial dentures favored a
proliferation of spiral organisms.
(El ghamrawy , 1976)
evaluated the effect of a removable partial denture mandibular
major connector design on the surrounding gingival tissues
Framework designs like Lingual plate contribute to ↑ plaque and
altered bacterial flora
McHenry et al 1992 The Journal of Prosthetic Dentistry Vol 68, Issue 5, Pages 799–803
Occlusal Forces Transmitted To Remaining Teeth
& Their Periodontal Tissues
Occlusal forces transmitted to abutment teeth by RPDs -
Jiggling as well as orthodontic component esp. in distal
extension RPD
Magnitude, direction & frequency of force vary among
patients and sites
Increased mobility of the abutment teeth ( Rissin et al 1979)
Good alveolar bone support
Good plaque control
Periodic recall visits
No PDL breakdown
Bergman et al 1982
Carlsson et al 1965
poor patient co-operation
Long recall interval
Gingivitis
Pocket deepening
Mobility
Compared abutment teeth of patients with RPDs, FPDs and
no prosthesis
RPD wearers - greatest plaque and calculus deposition,
probing depth & alveolar bone loss
Rissin et al. (1985) The Journal of Prosthetic Dentistry
Zlataric et al. (2002)
In an evaluation of 205 patients with RPDs, abutment teeth
showed more disease than non abutment with
↑Plaque index,
↑Gingival index,
↑ Probing depth
↑ Tooth mobility
↑ Gingival recession
Improperly designed clasps lead to excessive stresses &
occlusal traumatism and damage abutment teeth
During settling of posterior RPD ,clasp arm may
impinge on marginal tissue- if not supported by rests
Acrylic Partial Denture
Acrylic non-rigid material whose strength is improved
by ↑ the thickness
Bulky dentures more potential to damage soft tissues
Cause periodontal damage by
Physical stripping of gingiva
Damaging lateral forces
Increased plaque accumulation
Orthodontic Therapy
The periodontal reaction toward orthodontic appliances depends
on multiple factors
host resistance
the presence of systemic conditions and
the amount and composition of dental plaque.
Orthodontic fixed appliances induce an increase in the
volume of dental plaque
cause a shift in the type of bacteria (Petti et al 1997).
Direct trauma to supporting tissue
INTERFERENCE WITH PLAQUE CONTROL
Plaque - inflammation –gingivitis
Appliance per se causes plaque accumulation
Inability of the pt to adequately clean
Effect of orthodontic band
Main short term effects
gingivitis & gingival enlargement
Improved within 48 hrs of removal of band
(Baer and Coccaro 1964)
Gingival enlargement ↑ probing depth
May be due to Trapped plaque
Mechanical irritation caused by band or cement
Mechanical irritation can be caused by bands by contact
with gingival margins .
Chemical irritation by exposed cement at margin
Greater likelihood of food impaction in posterior
between arch wire & soft tissue
Microbiology &Orthodontic Band
Petti S et al 1997
Evaluated Microbiological and clinical changes
occurring during the first six months of
orthodontic therapy with fixed and removable
appliances
15 with fixed and 15 with removable appliances
Patients with fixed appliances counts, motile
rods, subgingival spirochetes and a of Gram
positive cocci.
in patient with removable appliances supragingival motile rods
and subgingival spirochetes
Van Gastel et al., 2007 fixed orthodontic
treatment may result in
localized gingivitis,
which rarely progresses
to periodontitis
• Adolescents -fixed therapy cause Loss of attachment of 1- 2mm
Alstad & Zachrisson 1979
• Higher prevalence of root resorption Trossello &
Gianelly 1979
• Failed to show any significant changes in adultPolson et al.
1988
Orthodontic Elastics &
SeparatorsInjudicious use rapid and severe periodontal
destruction
Elastic below height of contour has a Tendency to slip
apically
Danger of elastics slipping beneath the marginal gingiva &
detaching PDL – mentioned as early as 1870 by McQuillen
Band Placement
Stripping of junctionalepithelium. Extrusion
of cement into soft tissue -acute gingival or periodontal abscess
Forced Eruption of Impacted Teeth
Use of banded attachments & removal of excessive bone negative impact .
It compromise pdlattachment of adj teeth
Occlusal Consideration
Orthodontic movement - Unavoidable occlusal
traumatism - Affect health of periodontium
Disturbance of occlusion produces, although
temporarily- Jiggling type of forces
Root resorption
Ottolengui (1914), related root resorption directly to
orthodontic treatment
In 1927 root resorption was a subject of major concern to the
orthodontic field.
Katcham, demonstrated, with radiographic evidence, the
differences between root shape before and after orthodontic
treatment
The etiology of root resorption still remains unclear and
is complex, including genetic predisposition and
environmental factors Abass and Hartsfield, 2007
Types• Cementum or surface resorption with remodeling.
• Dentinal resorption with repair (deep resorption)-The
final shape of the root may or may not be identical to
original form.
• Circumferential apical root resorption-root shortening is
evident
Movements of roots outside the confines of alveolar process
- development of mucogingival problems esp in areas of thin
bone & gingiva
Forces during frontal & lateral
expansion of teeth
• Development of tension in marginal tissues
Stretching
• thinning of the soft tissues
If expansion
• bone dehiscence • Development of soft tissue recessions in presence of bacterial plaque &/or mechanical trauma like improper brushing
EXODONTIC PROCEDURES
Injudicious tooth removal initiate periodontal
disease or aggravate existing pathosis in the vicinity
Procedures affecting
periodontium
Manner in which facial and lingual flaps are raised
Manner in which the teeth are luxated and elevated
Degree of post-extraction debridement
Way in which the wound is closed
Practice of tightly suturing flaps for hemostasis
without regard for flap position -position that is too far
occlusal.
Since connective tissue does not attach to the enamel
surface -pseudopockets
Also the incorrectly positioned band of gingiva becomes non-
functional leading to exaggerated free gingival margin
Situation is esp serious if the original zone of attached gingiva
in the vicinity is minimal
Impacted 3rd Molar extraction
Creation of vertical defects distal to 2nd molar
Kugelberg et al. (1985)-
Retrospective study -215 patients 2yr after surgery
43.3%- probing depth > 7mm
32.1%- probing depth > 4mm
Kugelberg (1990)
evaluated Periodontal healing after 2 & 4 yrs in 51 cases
2yrs post operatively
16.7% ≤ 25 yrs – intrabony defect more than 4mm
40. 7%≥ 25 yrs- intrabony defects more than 4mm
4yrs post operatively
4.2 % ≤ 25 yrs – intrabony defect more than 4mm
44.4 %≥ 25 yrs- intrabony defects more than 4mm
Javier Montero et al 2011
The periodontal health of the second molar was found to
improve gradually after third molar surgery
Probing depth was gradually reduced by about 0.6 mm
quarterly, until a final depth of 2.6 was attained.
PERIODONTAL PROCEDURES
Calculus maybe dislodged and pushed into the soft tissue
during scaling
Inadequate scaling calculus to remain in the deepest
pocket area
Resolution of the inflammation at the coronal pocket area
Occlude the normal drainage
• Trauma to the marginal gingivaPolishing
Brush
• Generated heat may cause thermal damage leading to pulpitis
Polishing cup
Post flap surgery , common sequelae
Gingival recession
Inevitable sequence of periodontal surgery
Sensitivity
Exposed root surfaces become sensitive to heat, cold, mechanical
and chemical stimuli
Reduces over few weeks or months but occasionally may persist
for long period of time
Case reportsBurns due to elect cautery unit
Burn injury caused by heated ultrasonic scaler
Treatment of food impaction with a cold cure acrylic appliance resulting
in chemical burn and pathologic changes in periodontium
Severe ulceration of cheek mucosa due to irritation of molar tube.
The traumatic injury of the acrylic plate of
the pendulum applianceAccidental contact of cheek and alveolar
mucosa with formocresol
Severe periodontal damage by an ultrasonic endodontic
device
Overheating of a maxillary
central incisor caused
necrosis of soft tissue and bone
on the facial and mesial aspects
inflammatory response in the
adjacent nasal cavity
Patient chose to get
her teeth extracted
MISSING STRATEGIC TEETH AND THEIR NON
REPLACEMENT
Replacement of strategic teeth is often
overlooked in dental practice
Unreplaced missing teeth Drifting
of adjacent teeth &create conditions that lead to
periodontal disease
Initial tooth movement can be aggravated by
loss of periodontal support
Flaring of anterior teeth due to usage of anterior for chewing
Sinus Expansion Destroying Bone -MissingUpper Teeth
the sinus expand and destroy bone from the “inside out.”
Headaches from Missing Teeth
Failure to Replace First Molars
Tilting of 2nd & 3rd molar causing decreased
vertical dimension
Mandibular incisors tilt or drift lingually
Premolars move distally, lose their intercuspating
relationship with maxillary teeth and may tilt distally
Increased anterior overbite. Mandibular incisors strike
maxillary incisors & may traumatize the gingiva
Maxillary incisors - pushed labially & laterally
Anterior teeth extrude due to loss of incisal apposition
Formation of midline diastema
Sequale of non replacement of first molar
CONCLUSION
Iatrogenic factors play a considerable role in
periododontal diseases.When treating the patients
objectives of dentists must be clear ,to avoid any
undesirable outcomes of treatment. There is a need
to increase awareness among dental practitioners
about the role of iatrogenic factors in order to get
successful outcome of any dental therapy, which
unfortunately is ignored for a long time.