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DR.VEENA VENUGOPAL
FIRST YEAR POSTGRADUATE

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IATROGENIC FACTORS
 Inadequate dental
procedures that contribute
to deterioration of the
periodontal tissues
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Restorative dentistry
 improper use of rubber dam clamps
 matrix bands and burs
 lacerate the gingiva
 resulting mechanical trauma and inflammation.
 Overhanging margins of restorations and crowns
accumulate additional plaque by limiting the
patient’s access.
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 Overcontoured crowns and restorations tend to accumulate
plaque and possibly prevent the self cleaningmechanisms of
the adjacent cheek, lips,and tongue.
Overhanging margins
 Changing the ecologic balance of the gingival sulcus to an
area that favors the growth of disease associated organisms
(predominately gram negative anaerobic species) at the
expense of the health-associated organisms (predominately
gram positive species) and
 Inhibiting the patient's access to remove accumulated
plaque.
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 Proximal contact relation:
 The integrity and location of the proximal
contacts prevent interproximal food
impaction.
 Food impaction is the forceful wedging of
food into the periodontium by occlusal
forces.
 Classification of food impaction
 Plunger cusp
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 Cervical enamel projection (CEP) and enamel pearls
 They appear as narrow wedge-shaped extensions of
enamel pointing from the cementoenameljunction
(CEJ) toward the furcation area.
 CEP classified into….
 Grad 1 –CEJ of tooth to furcation entrance
 Grade 2 – approches entrance but doesn’t into
furcation
 Grade3 – extends horizontally into furcation
 The clinical significance of CEPs is that they are
plaque retentive and can predispose to furcation
involvement.
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Prosthesis
 poorly designed clasps, prosthesis saddles and pontics
 exert a direct traumatic influence upon periodontal
tissues.
 Ovate pontic is good compare to other pontics. plaque
easily removed from pontic because of convex surface
of pontics
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Orthodontic procedures
 Orthodontic therapy may affect the
periodontium by brackets favoring plaque
retention, by directly injuring the gingiva as a
result of overextended bands, chemical irritation
by exposed cement and by creating excessive,
unfavorable forces, or both.
Effect of band on periodontium
 Short term effect
 Long term effect
Microbiology around orthodontic band
Effect of orthodontic force on periodontium
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Extraction of impacted third
molar
 The extraction of impacted third molars results
in the creation of vertical bone defects distal to
the second molars.
 Careless use of elevators or forceps during
extraction results in crushing of alveolar bone.
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Malocclusion as contributing
factors
 Crowded or malaligned teeth is more difficult to
clean than properly aligned teeth.
 In deepbite, maxillary incisors impinge on the
mandibular labial gingiva or mandibular incisors
on the palatal gingiva, causing gingival and
periodontal inflammation.
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Habits as contributing
factors
 The tooth surface, usually the root surface, can be
abraded away by improper toothbrushing
technique, especially with a hard toothbrush.
 The defect usually manifests as V-shaped notches at
the level of the CEJ.
 Flossing & tooth picks can also cause damage to
dental hard and soft tissues.
 Flossing clefts may be produced when floss is
forcefully snapped through the contact point so that
it cuts into the gingiva. Also, an aggressive up and
down cleaning motion can produce a similar injury.
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Mouth breathing
 Mouth breathing can dehydrate the gingival tissues and
increase susceptibility to inflammation.
 These patients may or may not have increased levels of
dental plaque. In some cases, gingival enlargement may
also occur.
 Excellent plaque control and professional cleaning
should be recommended, although these measures may
not completely resolve the gingival inflammation.
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Tongue thrusting
 Tongue thrusting is often associated with an
anterior open bite.
 During swallowing the tongue is thrust forward
against the teeth instead of being placed against
the palate.
 When the amount of pressure against the teeth
is great, it can lead to tooth mobility and cause
increased spacing of the anterior teeth.
 This problem is difficult to treat but must be
recognized in the diagnostic phase as a
potentially destructive contributing factor.
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Factitious injuries
 Self-inflicted or factitial injuries can be difficult
to diagnose because their presentation is often
unusual
 These injuries are produced in a variety of ways
including pricking the gingiva with a fingernail ,
with knives, hair pins and by using toothpicks or
other oral hygiene devices.
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 Radiation therapy has cytotoxic effects on both normal cells
and malignant cells.
 Radiation treatment induces an obliterative endarteritis that
results in soft tissue ischemia and fibrosis while irradiated
bone becomes hypovascular and hypoxic.
Adverse affects of head and neck radiation therapy
 Dermatitis and Mucositis
 Muscle fibrosis andTrismus
 Xerostomia
 Use of a chlorhexidine digluconate mouthrinse may help
reduce the mucositis.
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 Xerostomia results in greater plaque accumulation and a
reduced buffering capacity from what saliva is left.
 The use of effective oral hygiene, professional dental
prophylactic cleanings, fluoride applications, and
frequent dental examinations are essential to control
caries and periodontal disease.
 Prophylactic antibiotics before receiving appropriate
nonsurgical periodontal therapy
 The risk of osteoradionecrosis must be evaluated before
extracting a tooth or performing periodontal surgery in
an irradiated site
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 Periodontal attachment loss and tooth loss was
greater in cancer patients who were treated with
high-dose unilateral radiation as compared with
the nonradiated control side of the dentition
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CONCLUSION
 Calculus therefore is a secondary etiologic factor for
periodontium. But its presence makes adequate
plaque removal impossible and prevents patients
from performing proper plaque control. its removal
from tooth surface is a primary requirement to
achieve periodontal health. The clinician should well
trained in the adequate removal of calculus which is
1st step in periodontal therapy.
 The design and sharpness of instruments ,
anatomical factors, depth of calculus deposition and
operator’s experience play role during subgingival
calculus removal.
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References
 Newman MG, Takei HH, Klokevold PR, Carranza FA.
Carranza’s Clinical Periodontology. Saunders Elsevier;10th
Edition.
 Lindhe, Karring, Lang. Clinical Periodontology & Implant
Dentistry. Blackwell Munksgaard; 5th Edititon. .
 SØREN JEPSEN, JAMES DESCHNER. Calculus removal and
the prevention of its formation
Periodontology 2000, Vol. 55, 2011, 167188
 Fairbrother KJ, Heasman PA: Anticalculus agents.
J Clin Periodontol 2000; 27: 285–301

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THANK YOU
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