PBL SMOKING CESSATION GROUP 2
LEARNING ISSUES What are the medical problem that associated with mobile tooth and bad breath?Eg) DM • The pathophysiology? • Medication that may cause xerostomia • Effect of smoking to periohealth Mobile tooth • causes & grading • Clinical features • management of mobile tooth Bad breath • Causes and effect • Management of bad breath Traumatic occlusion • How to access traumatic occlusion • causes • Clinical features • Management Severe staining • Causes and effect • Management • Tx option Fibrotic gum • Causes & Pathophysiology • Features • Management Management of hypersensitivity tooth & furcation involvement Based on OPG • How plaque influence the type of bone loss • Bone defect (causes, types and management) Designated OHI for the patient (smoker) • Toothbrushing technique • Types of mouth wash • Interdental brush • Smoking cessation
MECHANISMS OF INTERACTION BETWEEN DIABETES AND PERIODONTAL DISEASES. • Functions of cells. • Altered wound healing • Proinflammatory cytokines
Oral health related conditions reported to be asscociated with diabetes: • Periodontal disease • Dental caries • Oral candidiasis • Oral lichen planus • Xerostomia, burning mouth syndrome, alterations in taste
Effects of smoking on periodontal health • It mask clinical sign of periodontitis, due to effect of nicotine & other agents in smoke • Vasoconstriction • Reduce gingival bleeding & redness • Surface keratinization • # other studies show smoking may reduce the apoptotic mechanism in oral cavity > epithelial cell hyperplasia & increase in thickness of the overlying orthokeratin layer • # lower level of GCF related to nicotine related vasoconstrictor. • The reduction of vascular component of inflammatory response > reduce availability of antibodies > decreade in passage of leukocytes into periodontal tissue.
Effect of tobacco smoking in periodontium • More site with deeper pocket • Greater level of CAL/ bone loss • Accumulate more calculus • Demonstrate dose-response for PD destruction ( higher pack year, higher PD destruction)
Definition • Horizontal and to a lesser degree, axial movement of a tooth in response to normal force.
Aetiology • Excessive occlusal forces or premature contacts • Loss of tooth support (bone loss) • Pregnancy • Increase in the fluid content of the periodontal structures, an increased vascularity and a proliferation of capillaries into the periodontal tissues. • Systemic diseases • non-Hodgkin’s lymphoma, scleroderma and Cushing’s syndrome • Severe periodontal inflammation (periodontitis) • teeth with a healthy but reduced periodontal support (that is, in patients after successful periodontal treatment) • in the ﬁrst weeks after periodontal surgery • pathologic process of the jaws
Splinting : • Indications • mobile multiple of teeth due to gradual alveolar bone loss • increased tooth mobility + pain or discomfort in the affected teeth • To gain stability, reduce or eliminate the mobility, and relieve the pain and discomfort. • Contraindications • occlusal stability and optimal periodontal conditions cannot be obtained
Principles of Splinting • objective: to decrease movement 3 dimensionally • ideal splint should reorient and redirect all occlusal and functional forces along the long axis of teeth, prevent tooth migration and extrusion, and stabilize periodontally weakened teeth
Types of Splint • Provisional Splint • Objective: to absorb occlusal forces and stabilize the teeth for a limited amount of time. • External: fabricated using ligature wires, nightguards, interim fixed prostheses, and composite resin restorative materials • Internal: fabricated using composite resin restorative material with or without wire or fiber inserts • Uses: • adjuncts to many different types of treatment • treating periodontally compromised patients with conventional fixed prosthodontics • re-evaluation : to determine if treatment should proceed to a definitive restoration • Occlusal devices are often recommended to patients with a history of bruxing and clenching to help stabilize teeth following selective occlusal adjustment.
Definitive Splint • placed only after the completion of periodontal therapy and once occlusal stability has been achieved in order • to eliminate or prevent occlusal trauma • increase functional stability • Improve aesthetics on a long-term basis. • includes conventional fixed prostheses because they provide definitive rigidity and are better able to control and direct occlusal forces than removable splints • Partially edentulous patients: complete coverage fixed partial denture.
Causes • Tongue & tongue coating • Food remnant remain trapped on irregular surface of dorsal of the tongue • Periodontal infections • Level of VSC in mouth correlate positively with depth of periodontal pocket, the deeper the pocket, the more the bacteria and VSC(volatile sulphur compound) amount increase in number • Other relevant malodor pathologic menefestations of periodontium are pericoronitis, major recurrent oral ulceration, herpetic gingivitis, necrotizing gingivitis • # microbiology observation ulcer infected with gram –veanerob significantly more malodour (prevotella and porphyromonas sp) • Dental pathologies • Deep carious lesion with food impaction • Extraction wound with blood & purulent discharge • Acrylic denture (frequent used at night, poor denture hygiene) • Dry mouth • Has high level of plaque on teeth & extensive tongue coating • Other causes of xerostomia are, medication, alcohol abuse, sjogren syndrome and diabetes
Treatment • Mechanical reduction of intraoral nutrient and microorganism • Cleaning of tongue with toothbrush/ tongue scrapper ( decrease halitosis level 75% over 1 week) • Chewing gum control bad breath temporarily as it stimulate salivary flow • Chemical reduction of oral microbial load • Mouth rinsing common practice such as, chlorhexidine, chlorine dioxide &triclosan • Chlorhexidine ( most effective antiplaque& antigingivitis agents), antibacterial action done by disruption of bacterial cell membrane by chlorehexidine molecule resulting in lysis of cell. • Masking the malodor • Mouth spray, lozenges containing volatiles with pleasant odor for a short term.
Extrinsic staining Non-metallic stains: • The non-metallic extrinsic stains are adsorped onto tooth surface deposits such as plaque or the acquired pellicle. • The possible aetiological agents include dietary components, beverages, tobacco, mouthrinses and other medicaments. • The most convincing evidence for the extrinsic method of tooth staining comes from the differing amount of stain found in a comparison of smokers and non-smokers.45 • The staining effect of prolonged rinsing with chlorhexidine mouthrinses46 and quarternary ammonium compounds used in mouthrinses47 is of considerable interest to the dental profession.
Management: • Bleaching • Internal/non-vital • External/vital • Composite resin restoration • Veneer(composite resin or porcelain) • Crown • Air abrasion
Causes • drug induced: anticonvulsants, calcium channel blockers, immunosuppressant • Associated with systemic factor: pregnancy, vitamin C deficiency, leukemia, neoplasm • Inflammatory • Hereditary gingival fibromatosis
Pathophysiology • Nicotine increase production of CCN2/CTGF protein without increasing mRNA expression. • Type I collagen mRNA and protein also increase and significantly blocked by a CCN2/CTGF neutralizing antibody • Overexpression of CCN2can exacerbate fibrosis • It is suggested that the induction of CCN2/CTGF by nicotine may be a major promoter of periodontal fibrosis caused by smoking
Features • Consistency: firm, hard.associated with pink colour stippling, bleeding only in depth of pocket • Surface texture:Hard and firm with stippling. May be lobulated • Position of gingival margin: Enlarged gingiva. Margin is higher on the tooth, above normal. Pocket deepened. Recession present with margin more apical, exposed root surface
Management • Gingivectomy followed by plaque control
Definition : • refers to commonly occurring conditions in which the bifurcations and trifurcations of multi-rooted teeth are invaded by the disease process.
Local factors • Root trunk length • the distance from CEJ and entrance of furcation • shorter the root trunk, less attachment need to be lost before furcation involved • easier to be treated if exposed • Root length • Teeth with long root trunk and short root hard to be treated when furcationinvolved • Root form • Mesial root of most first and second mand.molar and mesiofacial root of max first molar typically curved to the distal site. • Interradicular dimension • Closely approximated root difficult to clean • Anatomy of furcation • Presence of bifurcation ridges, accessory canal, may complicate the treatment and maintainance. • Cervical enamel projection • It can affect plaque removal, and nonsurgical treatment. Need to be removed to facilitate the maintainance
Management : • Objectives: • To eliminate the microbial plaque from the exposed surface of the root. • To establish the anatomy of affected surface that facilitates self performed plaque control.
Characteristic : • Short sharp pain. • Arising from exposed dentine • In response to stimuli typically thermal, evaporative, tactile, chemical or osmotic • Which cannot be described to any other form of dental defect or pathology
Management: • Control aetiological factors to prevent failure or recurrence • Complete history taking ( about the pain and sensitivity) • Clinical examination • Tactile exam with probe • Gentle flow of air from syringe • Percussion & biting : sensitive? • Radiograph: any pathology? • Exposure of dentin,crackedcusp,occlusal interference • Consider all ddx • Treat secondary condition that has similar symptoms (restoration on open dentin,occ interference) • Identify aetiology and predisposing factors • Advice diet • Correct toothbrush type,technique,frequency
Management: • Home care: • Desensitizing toothpastes : • Contain potassium salts (nitrate or chloride), strontium salts (chloride and acetate). • 2 weeks of application twice a day • Professional management: • Fluoride : varnish and gel (it occlude by crystallinization of dentinal tubule) • Oxalate salts : potassium oxalate or ferric sulphate (form calcium oxalate crystal in tubule • Arginine : attract calcium to tubule,plug and seal it. • Periodontal mucogingival surgery : root coverage with GTR • Resin adhesives • Laser therapy : coagulates tubular protoplasm-block tubules • Endodontic tx : pulp extirpation and RCT.
Outline • Definition . • Physiologic adaptive capacity of the periodontium to occlusal forces. • Factors that help increase traumatic forces. • Classification • Clinical features. • Radiographic findings. • Treatment
Definition • “ a condition where injury results to the supporting structures of the teeth by the act of bringing the jaws into a closed position .”(Stillman -1917) • “ damage in the periodontium caused by stress on the teeth produced directly or indirectly by teeth of the opposing jaw.” (WHO in 1978)
Physiologic adaptive capacity of the periodontium to occlusal forces • The periodontium attempts to accommodate the forces exerted on the crown. • This adaptive capacity varies in different persons and in the same person at different times. • When occlusal forces exceeds the adaptive and reparative capacity of the periodontal tissues, tissue injury results (trauma from occlusion)
Factors that help increase traumatic forces: (Magnitude, direction & duration) • When magnitude of occlusal forces is increased: • the periodontium responds with a widening of the periodontal ligament space. • an increase in the number and width of periodontal ligament fibers. • increase in the density of alveolar bone.
Cont… • B) Direction of the occlusal forces. • the periodontal ligament fibers are arranged so that the occlusal forces are applied along the long axis of the tooth. • Change in the direction of the occlusal forces lead to change the orientation of periodontal ligament fibers.
Cont… • Duration and frequency of occlusal forces. • Constant pressure on the bone is more injurious than intermittent forces. • The more frequent the application of an intermittent force, the more injurious the force to the periodontium.
Classification • Acute and Chronic Trauma • Primary, SecondaryandCombined TFO
Acute trauma from occlusion • results from an abrupt occlusal impact, such as that produced by biting on a hard object (e.g., an olive pit). In addition, restorations or prosthetic appliances that interfere with the direction of occlusal forces on the teeth may induce acute trauma. (CARRANZA'S clinical periodontology)
Acute trauma from occlusion • Clinical features : • Tooth pain. • Sensitivity to percussion. • Tooth mobility.