week one - modifiable/nonmodifiable factors + risk assessment

Question 1

provide two examples for each of the four types of risk factors for caries

Answer 1

1. local
   - poor OH
   - tooth anatomy / existing restos
2. systemic
   - xerostomia related to various medications or conditions
   - high bacterial counts
3. environmental
   - inadequate fluoride exposure
   - frequent consumption of cariogenic foods [lifestyle]
4. lifestyle
   - low SES
   - disabilities/impairements making OH activities more difficult

caries risk factors div into two broad catergories
1. primary
- act directly on biofilm
- eg saliva, diet, fluoride

2. modifying
   - indirect influence
   - eg low SES, lifestyle, prev dental/compliance hx

Question 2

briefly describe the aetiology of periodontal disease and list the five domains of risk factors

Answer 2

occ when balance is changed between pathogenic bacteria and host’s inflammatory/immune responses
- can be affected by local/systemic risk factors
- grouped as modifiable/non-modifiable risk factors

1. environmental [dysbiotic subgingival biofilm]
2. genetic risk factors
3. lifestyle eg smoking, poor diet, stress
4. systemic diseases eg diabetes
5. other factors such as tooth related, occlusal/functional problems, iatrogenic factors

Question 3

describe local risk factors for periodontal disease

Answer 3

local contributing factors ^ plaque retention/pathogenicity or directly damage periodontium
- possible to eliminate some local cont factors eg removal of overhangs
- possible to compensate for local factors that cant be eliminated eg good self care arounf crowded or open contact

eg of local risk factors
- pt habits
- faulty restos/appliances
- carious lesions
- tooth morpho
- occlusal forces
- food impaction
- mature plaque accumulation
- malocclusion/malalignment
- incompetent lip seal
- calculus

Question 4

describe systemic risk factors for periodontal disease

Answer 4

1. smoking/alcohol
   - strongly assoc w tooth loss
   - impairs healing response, selects for periodontal pathogens, impacts host response
2. smoking-gingivitis
   - heavy smokers present clinically w thickened, fibrotic gingival tx
   - devel of ging is delayed due to reduced blood supply + suppressed normal immune response to accumulation of plaque
   - masking of bleeding ^ may lead to failure to recognise presence of periodontal disease
3. smoking-periodontitis
   - rate of periodontitis progression is more rapid among smokers
   - smoking assoc w deeper pockets and ^ bone loss + smokers exhibit less reductions in probing depths
   - poor wound healing of tx in surgical/non-surgical tx
4. obesity
   - ^ BMI = ^ risk [dose-response relationship]
   - chronic systemic inflammation - suggested mechanism = contribution of adipose tx [dysregulated bone metabolism] + release of pro-inflammatory mediators and host immune response
5. diabetes [Type I/2] [elevated blood glucose levels]
   - due to defects in insulin action/prod. =**systemic inflammatory response **
   - severity = higher in pts w poor glycaemic control
   - ^ alv bone loss in type 2
   - suggested mech
   defect in PMN activity [Polymorphonuclear neutrophils - infection defence]

AGE accumulation [Advanced glycation end products - glycated proteins/lipids after sugar exposure] - ^ inflammation

^ lvls of inflammatory mediators
- PGE2
- TNF

6. stress
   - correlation between chronic perio dx + pyschosocial stress status = ability to cope may modify disease progression
   - sugg mech = dysreg of host immune response and impact of stress of behaviours
7. haematological disorders
   - eg leukemia
   - impairs host immune response to biofilm and periodontal pathogens
8. osteoporosis [reduction in bone mineral density]
   - POTENTIAL RISK FACTOR - FURTHER STUDIES NEEDED
   - some studies to suggest possitive assoc with alv bone height, CAL and periodontitis
9. HIV/AIDS
   - immunodifiency can manifest necrotising stomatitis, linear gingival erythema, ANUG, ANUP
10. hormonal fluctuations
    - pregnancy
    - menstruation
    - menopause
    - contraceptive pill
    - hormone replacement therapy
11. genetic
    - familial aggregation of aggresive types of periodontal disease
12. other factors that affect periodontium
    - medications that affect gingival overgrowth [phenytoin, cyclosporine, Ca channel blockers]
    - effect on saliva flow = xerostomia

Question 5

describe the three risk characteristics of periodontal disease

Answer 5

1. age
   - prevalence/severity of perio ^ w/ age
   - likely related to length of time - periodontal tx exposed to bacterial plaque
2. gender
   - higher documented prevlance in men [57%] compared to women [39%]
   - sugg gender bias in pathogenesis
3. SES
   - related to social determinants of health

Question 6

describe three other diseases in which periodontal disease is a risk factor

Answer 6

1. cardiovascular disease
   - systemic inflammatory response + impact of periodontal pathogens eg P.gingivialis in atherosclerosis development
2. pre and low birthweight
   - PLBW <2500g
   - sugg mech - bacterial by-products and assoc host inflammatory mediators and bacterial spreading
   - PLBW and perio also share similar risk factors
3. diabetes
   - impact of pre-existing perio on devel of incidient DM = unclear
   - perio tx assoc w improved glycaemic control

Question 7

describe the risk factors for
1. oral cancer
2. fungal [candida] infections
3. trauma

Answer 7

1. oral cancer
   - tobacco/alcohol
   - HPV
   - excess BW
2. fungal [candida] infections
   - weakened immunity [HIV/AIDS, immunosuppresants]
   - poorly controlled DM - sugar encourages growth of candida
   - conditions/meds causing xerostomia
3. trauma
   - greater overjet
   - male gender
   - incompetent lip seal
   - tongue piercings
   - participation in contact sports
   - excessive drinking

Question 8

list the visual flow ranges for saliva testing and their indications

Answer 8

< 3.5 mL = v low
3.5 - 5.0 mL = low
> 5.0 mL = normal

Question 9

describe sensibility tests [2]

Answer 9

1. percussion testing
   - indicates PDL inflammation
   - tapping on multiple teeth to reveal if a particular one is causing pain
2. pulp sensibility testing
   - thermal testing / cold test
   - may yield following results
   - no response
   - moderate transient response
   - painful response that subsides/lingers after stimulus removal

Question 10

describe the caries imbalance
1. disease indicators
2. risk factors
3. protective factors

Answer 10

1. disease indicators
   - white spots
   - restorations <3 yrs
   - enamel lesions
   - cavities/dentin
2. risk factors [BAD]
   - bad bacteria
   - absence of saliva
   - dietary habits [poor]
3. protective factors
   - saliva and sealants
   - antibacterials
   - fluoride
   - effective diet

Question 11

define CAMBRA and the distinctions between the risk catergories for patients > 6 yo

Answer 11

“caries management by risk assessment”
- risk status determined by balance/imbalance of pathological and protective factors in each pt
- consistent w MID

high risk
- 1 or more diseae indicators = high risk
- in conjunction w hyposalivation = extreme risk

moderate risk
- if not obv at high/extreme risk and doubt about low risk
- monitored w appropriate measures eg fluoride

low risk
- no disease indicators, very few/no risk factors, many protective factors

Question 12

distinguish between the CAMBRA risk catergories for pt < 6 yo

Answer 12

high risk
- 1/more disease indicators
- risk factors definitively outweigh protective factors
- mother/caregiver w current/recent decay - most likely high caries risk for child also

moderate risk
- no disease indicators
- risk factors and protective factors = balanced

low risk
- no disease indicators
- few/no risk factors
- prominent protective factors

Question 13

define NCTL, distinguish between attrition/erosion/abrasion/abfraction and outline their risk factors

Answer 13

NCTL = non carious tooth loss

1. attrition
   - loss of tooth tissue from tooth-tooth contact
   - bruxism, uneven occ loading
2. erosion
   - loss of tooth tx from acidic dissolution
   - acidic bev/foods
   - acid reflux
   - social factors
3. abrasion
   - loss of tooth tissue from foreign objects or conditions [not tooth-tooth related]
   - toothbrush/technique
   - piksters
4. abfraction
   - loss of tooth from occlusal forces
   - wedge shaped damage at gingival margin