Iatrogenic Factors

Responsible For
Periodontal Disease
Jaimini Dave
MDS Part I
 INTRODUCTION :

 For a natural dentition to function optimally, the supporting tissues must be in a state of
health.

 Periodontal disease results from extension of inflammatory process initiated in gingiva

to the periodontal tissue.

 Manipulation of periodontium during dental procedures and careless or injudicious

therapeutic procedures may result in injuries to periodontium.
 Iatrogenic  Greek word

IATROS • PHYSICIAN

GENNAN • TO PRODUCE

 Iatrogenic injury is a broad term that may be defined as “ harm, hurt, damage or
impairment that results from the activities of a doctor. ( AAP: Glossary of periodontal terms,
2001)

 Iatrogenic injury produced by either an inadvertent or erroneous treatment, or may be

a result of either act of commision or act of omission by the therapist. (Vadersall et al, 1975)
 IATROGENIC FACTORS:

Inadequate dental procedures that contribute to the deterioration of the periodontal

tissues .
1. Restorative 3.
2. Endodontic
dental Prosthodonic
procedures
procedures procedures

4. Orthodontic 5. Exodontic 6. Periodontic

therapy procedures procedures
 1. RESTORATIVE DENTAL PROCEDURES :

restorations
periodontium
designed
Healthy
Properly

 Marginal periodontium  Area of Restorative Dentistry & Periodontics overlap

 Attention should be paid to the response of the periodontium to the irritants arising from
careless techniques, which can initiate or add to existing gingival inflammation.
 CONCEPT OF BIOLOGICAL WIDTH

Term applied to dimensional width of the

dento gingival junction (tissue occupying
the area between the base of the gingival
sulcus and alveolar crest)

Garguilo et al. (1961) measured in cadavers,

dimensional relationship between the
alveolar crest, the length of epithelial
attachment and sulcus depth is consistent.
 Minimum of 3mm of gap between restorative margins and bone (Rosenberg et al.1999,

Ponnterio & Carnevale 2001)

 This allows for adequate biological width when restoration is placed 0.5 mm within gingival

sulcus.

 Clinically, this information is applied to diagnose any biologic width violations when the

restoration margin is placed 2mm or less away from the alveolar bone and the gingival

tissues are inflammed with no other etiologic factors evident. Two different responses can

be observed from the involved gingival tissues.

Biological width evaluation

1. Clinical assessment

2. Radiograph

3. Bone sounding
VIOLATION OF BIOLOGICAL WIDTH

Body
Gingival attempts to
Unpredictabl
Tissue recreate the
e bone Loss
Recession biological
width

Gingivitis
Deep margin Bone level
developes &
placement unchanged
persists
 MARGINS OF RESTORATION
The placement of the restoration margin depends greatly on

 Esthetics
 Need for additional retention of the restoration
 Degree of personal oral hygiene
 Susceptibility of the individual to root caries
 Susceptibility of the marginal gingiva to irritants
 Morphological characteristics of the marginal gingiva
 Degree of gingival recession
 Severe cervical abrasion
• Not accessible for polishing and cleansing margins
• If placed too far below violate the Subgingival
biologic width
• Earlier thought to retain plaque and cause margin
inflammation Equigingival
• Well tolerated – smooth and polished
margin
• Placed in non aesthetic area
• Well tolerated Supragingival
 The location of the gingival margin of a restoration is directly related to the periodontal

health status (Silness et al., 1980).

 Subgingivally located margins are associated with large amounts of plaque, more severe

gingivitis, and deeper pockets. Margins placed at the level of the gingiva induce less severe

conditions; and supragingival margins are associated with a degree of periodontal health

similar to that seen with intact control surfaces. (Silness et al., 1980)
 Numerous studies have shown a positive correlation between subgingival margins and

gingival inflammation. (Gilmore N et al., 1971; Karlsen K et al., 1970; Sorensen J et al.,

1986).

 It has also been shown that even high quality restorations, if placed subgingivally, will

increase plaque accumulation, gingival inflammation, (Leon A R,1976; Mueller H P, 1986)

and the rate of gingival fluid flow. (Normann W et al., 1974)

Margin Placement Guidelines using Sulcus Depth as 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- Gingevectomy

performed to reduce the depth to 1.5mm
 SOURCES OF MARGINAL ROUGHNESS

 Roughness in the subgingival area is considered to be the major cause of plaque build

up and the resultant inflammatory response. (Silness J, 1980)

The subgingival zone is made up of the crown and the margin of the restoration, the

luting material, and the prepared tooth surface.

Several types of roughness have been described like :

 Grooves and scratches in the surface of carefully polished acrylic resin, porcelain, or gold
restorations

 Separation of the cervical crown margin and the cervical margins of the finishing line by the luting
material, exposing the rough surface of the prepared tooth.

 Dissolution and disintegration of the luting material, causing crater formation between the
preparation and the restoration.

 And the inadequate margin fit of the restoration.

 Tissue respond more to surface roughness than composition of material (Adamcyzk E,
Surface Roughness
Speichowics E, 1990)

Bacteria protected
-Survive longer
Roughness affects from natural Rough surfaces ↑area
the Initial Adhesion removal forces & -Reversible to for adhesion by 2-3
irreversible times
& Colonisation oral hygiene
attachment
measures

Procedures that Increase Roughness

Polishing paste on enamel at high speed & load

Polishing paste on restorative material
Application of fluoride gel on porcelain
Air powder abrasive systems on all materials
OVERHANGING DENTAL RESTORATIONS

An extension of restorative material beyond the confines of a cavity preparation.

Detection of overhanging restorations with radiographs.

Providing ideal location for the accumulation of plaque

Changing the ecological balance of the gingival sulcus area to one that favors the growth of
disease associated organisms (gram-negative anaerobic species) at the expense of the health
associated organisms (gram-positive facultative species) (Lang et al., 1983).
More bone loss, attachment loss & inflammation adjacent to overhangs

(Gilmore and Sheiham 1971, Jeffcoat and Howell 1980, Eid 1987)

Deeper pockets are found adjacent to overhanging restorations than controls

(Burch et al. 1976, Gorzo et al. 1979Claman et al

1986)

Highly significant associtiation b/w bone loss and overhanging restoration

(Hakkaranein & Ainamo 1997, Jeffcoat & Howell 1980)

Removal of overhangs permits more effective control of plaque and reduction of

inflammation and small increase in bone height.

(Gorzo et al. (1979), Jeffcoat & Howell ( 1980))

 Inter-dental Contact Relationships

Interproximal contact areas  commonly overcontoured

Impinge upon interdental soft tissues  vulnerable to periodontal breakdown.

Jeopardizes effective oral hygiene measures

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

Broadened proximal contacts constrict both occlusal and interdental embrasures.

Difficulty to clean the interdental area

Characteristic changes of the interdental tissues

Facial and lingual hyperplasia of interdental papilla

Microbial invasion

Inflammation and edema

Osseous involvement
 Facial and Lingual Contour

Facial / Lingual bulge  protect free gingival margin from traumatic effects of mastication

Original contour  Functional Stimulation and Maintain gingival health

Overcontouring prevents normal cleansing action of musculature & allows food to

stagnate in over protected sulcus (Morris 1962, Wagman 1977)
Occlusal Morphology of Restoration

I ncr eased Bucco l i ngu al W i dt h of O ccl us al Ta bl e

More axial stress transmitted to periodontium with wide Greater incidence of cross- arch & cross tooth balancing
occlusal table than narrow interferences during lateral excursive forces
 Material

 In general, restorative materials are not inherently injurious to the periodontal tissues. (Kawakara
et al, 1968)
 One exception to this may be self-curing acrylics. ( Waerhaug et al, 1957)
 Plaque that forms at the margins of restorations is similar to that founded on adjacent
nonrestored tooth surfaces. The composition of plaque formed on all types of restorative
materials is similar, with the exception of that formed on silicate. (Newman et al, 1994)
 Although surface textures of restorative materials differ in their capacity to retain plaque, all can
be adequately cleaned if they are polished and accessible to methods of oral hygiene. (Wise et al,
1975)

 Nickel – allergic reaction in 9% of people (Pelton L ,1979)

 Suseptible people pocket formation & deep vertical osseous defects (Bruce & Hall 1995)
 INJURY TO THE PERIODONTIUM BY RESTORATIVE PROCEDURES

Placed too Stripping of junctional epithelium and

●

gingival connective tissue attachment

Application of Rubber subgingivally
Dam and Matrix

Placed for Ischemia to the degree that sloughing of

●

tissue and subsequent gingival recession

too long
 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.

The wedge should not encroach towards the contact area: this will deform the matrix
and leave a large approximal gap under the contact point
 Taking Impression

Impressions require use of retraction cords to displace the free gingival tissues.

May cause damage to subgingival tissue. (Usually reversible)

The injudicious use of gingival-retraction techniques often can injure the soft tissues
and cause permanent alterations, such as recession.

Dry retraction cords  stripping of junctional & sulcular epithelium while removal
Electrosurgical retraction  recession & loss of attachment

Not indicated in regions of inflammation or of extremely thin gingival tissue

Even with healthy gingiva, misuse can cause devastating damage

Retained elastic impression materials, within periodontal tissues after removing

impression  massive loss of attachments
(O’ Leary et al. 1973)
 Provisional Restoration

 Made without consideration for periodontium can cause the disturbance.

Over extended temporary crowns may result in permanent gingival alteration in intedental region
or facial and lingual surface and may lead to gingival hyperplasia or recession.

Under extended temporary crowns may contribute to dentinal hypersensitivity by interfering with
adequate oral hygiene measures.

Poor proximal contact relationship may lead to food impaction and retention.
 2. ENDODONTIC PROCEDURES

Root perforations – common complication of endodontic

treatment .

Artificial communication b/w root canal system and

supporting periodontium.

During root canal treatment the most common reason for

perforation was attempting to negotiate calcified canals.
(42%) ( McCabs et al, 2006)
Root perforations occur during
Factors Affecting Prognosis

Access cavity preparation

Root canal preparation Location of perforation- most imp
Post space preparation
Time lapse b/w occurrence & treatment

Size of the perforation

Can be
Cervical
Midroot
Apical
Crestal root perforations  most susceptible to epithelial
migrations & rapid pocket formation

Perforations in furcation areas  crestal root perforations

because of proximity to epithelial attachment secondary
periodontal involvement

Inflammatory lesions in the marginal periodontium  increased probing depth,

suppuration, increased tooth mobility and loss of fibrous attachment
 3. PROSTHODONTIC PROCEDURES

When lost teeth are replaced  introduction of new hard surfaces susceptible to
plaque formation

Also, inflammatory tissue reactions of mucosa covering alveolar ridge if closely

associated with bridge pontics. (Silness 1980)
 Pontic Designs

 Manner in which pontic is designed & adapted to edentulous ridge determines health of

the surrounding tissues.

 The undersurface of pontics in fixed bridges should barely touch the mucosa.

 Access for oral hygiene is impeded by excessive pontic-to-tissue contact, thereby

contributing to plaque accumulation, which will cause gingival inflammation and possibly

formation of pseudopockets. ( Flemming et al, 1991)

 Modified ridge lap

Saddle or ridge lap

Hygienic pontic
 Removable Partial Denture

 After the insertion of partial dentures, the mobility of the abutment teeth, gingival
inflammation, and periodontal pocket formation increase. (Bissada et al, 1974)

 Because partial dentures favor the accumulation of plaque, particularly if they cover
the gingival tissue.

 Partial dentures that are worn during both night and day induce more plaque
formation than those worn only during the day. (Bissada et al, 1974)
 These observations emphasize the need for careful and personalized oral hygiene

instruction to avoid harmful effects of partial dentures on the remaining teeth and

periodontium. (Bergman et al, 1971)

 The presence of removable partial dentures induces not only quantitative changes in

dental plaque" but also qualitative changes, promoting the emergence of spirochetal

microorganisms. (Ghamrawy et al, 1976)

 Coverage of Marginal Gingiva with Parts of RPD

 Covering more gingival tissues  gingivitis  periodontal disease

 Mucosal-borne RPD with increased covering of the gingival margin without relief 
tend to settle down  mechanically damage the tissues

 Bissada et al. 1994- compared 3 diff designs of denture base in relation to marginal
gingiva
Coverage without relief  severe changes
Uncovered marginal gingiva  least changes
4. ORTHODONTIC THERAPY

 Orthodontic appliances

 retention of bacterial plaque and food debris

Specific microbiology and
orthodontic band
Effect of Orthodontic Elastics & Separators

Injudicious use  rapid and severe periodontal destruction

Elastic below height of contour  Tendency to slip apically

Danger of elastics slipping beneath the marginal gingiva & detaching PDL – mentioned
as early as 1870 by McQuillen
Trauma Related to Orthodontic Procedures

●
Stripping of junctional epithelium
Band Placement ●
Extrusion of cement into soft tissue  acute gingival
or periodontal abscess

Forced Eruption of Use of banded attachments & removal of excessive

●

bone  negative impact

Impacted Teeth ●
Esp. in lack of plaque control
 ROOT RESORPTION

 Excessive orthodontic forces also increase the risk of apical root

resorption. (Brezniak et al, 1993)
 The prevalence of severe root resorption, as indicated by resorption
of more than one third of the root length, during orthodontic
therapy in adolescents has been reported at 3%. (Kaley et al, 1991)
 The incidence of moderate to severe root resorption for incisors
among adults age 20 to 45 years has been reported 24.5%, after
treatment. ( Lupi et al, 1996)
 It is important to avoid excessive force and too-rapid tooth
movement in orthodontic treatment.
 Gingival recession and clefts

 Teeth with adequate gingiva occasionally develop localized recession during orthodontic
treatment.
 This is assumed to occur with excessive forces that hinder the repair and remodeling of the
alveolar bone.
 However, it is more likely that the direction and extent of movement have forced the tooth
through the cortical plate, while the remaining gingival attachment appears relatively free of
inflammation.
 Example: when molar with wide divergent roots is moved is to the space of narrow premolars
alveolar zone.
 Further more, when teeth are extracted as a part of treatment the orthodontic closure of the
extraction space may give rise to gingival invagination or clefting, in the immediate areas
(Robertson et al 1977).
 5. EXODONTIA PROCEDURE

Injudicious tooth removal  initiate periodontal disease or aggravate existing pathosis in the
vicinity.

Errors Adversely 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  exaggerated

free gingival margin

Situation is esp serious if the original zone of attached gingiva in the vicinity is minimal
 Extraction of Impacted 3rd Molar

 Creation of vertical defects distal to 2nd molar

 Clinical studies have reported that the extraction of impacted third molars often results

in the creation of vertical detects distal to the second molars.( Ash et al, 1962)

 This iatrogenic effect is unrelated to flap design and appears to occur more often when

third molars are extracted in individuals older than 25 years. (Kugelberg et al, 1992)

 Other factors that appear to play a role in the development of lesions on the distal

surface of second molars, particularly in those older than 25 years, include the presence of

visible plaque, bleeding on probing, root resorption in the con-tact area between second

and third molars, presence of a pathologically widened follicle, inclination of the third

molar, and proximity of the third molar to the second molar. (Kugelberg et al, 1992)
 6. PERIODONTAL PROCEDURES

Post- prophylaxis Periodontal Abscess

Calculus maybe dislodged and pushed into the soft tissue

Inadequate scaling calculus to remain in the deepest pocket area

Resolution of the inflammation at the coronal pocket area

Occlude the normal drainage
Entrapment of the subgingival flora in the deepest part of the pocket

(Dello Russo, 1985)

 Polishing ●
Trauma to the marginal gingiva
Brush
Improper use of
Generated heat may cause thermal
●

Polishing cup damage  pulpitis

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
 Non- Replacement of Strategic Teeth

Replacement of strategic teeth  often overlooked in dental practice

Unreplaced missing teeth  Drifting of adjacent teeth  can create conditions that
lead to periodontal disease

Initial tooth movement  aggravated by loss of periodontal support

FAILURE TO REPLACE FIRST MOLARS
CONCLUSION :

 A healthy periodontium is a pre-requisite for any form of dental treatment to be given.

 Thus, in an interdisciplinary approach the periodontal health should be given due consideration
before during and after any treatment modality.

 Clinicians should also bear in mind the consequences of unplanned treatment because in the
process of eliminating one problem there may be birth of another with greater consequences in
terms of tooth loss.

 The iatrogenic factors affecting the periodontium can be avoided thus resulting in a good
functional outcome.
THANK YOU…