ETIOLOGY OF PERIODONTAL DISEASES ‫ وضاح عبد الناصر نعمان الحاج‬/‫د‬

ETIOLOGY OF PERIODONTAL DISEASES

The clinical manifestations of periodontal disease result from a complex

interplay between bacteria found in dental plaque, the host tissues and time.

Etiology of periodontal diseases

Dental plaque ( Microorganisms)

Predisposing factors
a- Local (Calculus, Bad restorations, retentive factors)
b-Systemic (malnutrition, Endocrine … etc)

• Local factors
- Dental plaque - Calculus - Malocclusion
- Restorative Dentistry Procedures - Orthodontic Therapy
- Design of R. Partial Dentures - Food impaction - Tobacco Use
- Tooth Brush Trauma - Abnormal habits - Iatrogenic Factors

• Systemic factors
- Endocrine Disorders - Immunodeficiency Disorders
- Hematologic Disorders - Medications
- Psychosomatic Disorders - Nutritional Influences
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 ETIOLOGY OF PERIODONTAL DISEASES ‫ وضاح عبد الناصر نعمان الحاج‬/‫د‬

Dental Plaque
Dental plaque can be defined as the soft deposits that form the biofilom adhering to
the tooth surface or other hard surfaces in the oral cavity, including removable and
fixed restorations.

• There are two types of dental Plaque:

Plaque Composition
1_ Microorganisms: which exists within an intercellular matrix?

a- Gram positive: Streptococcus. sanguis, Actinomyces viscousus. (initial

colonizers)
b- Gram negative: Provetella intermedia, Fusobacterium nucleatum. (secondary
colonizers)
2_The intercellular matrix: which consists of :
A- Organic components: Polysaccharides, proteins, glycoproteins and lipid
material.
B- Inorganic components: Predominately calcium and phosphorus and other
minerals such as sodium, potassium and fluoride

Clinical appearance of plaque

1- White, greyish or yellow in colour. 2- Globular appearance.

3- Mostly on gingival third of the tooth surface
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 ETIOLOGY OF PERIODONTAL DISEASES ‫ وضاح عبد الناصر نعمان الحاج‬/‫د‬

Materia Alba
It is a white, soft deposits occur around the necks of the crown which consist of food
debris, desquamated epithelium cells. It is usually associated with poor oral hygiene;
and serves as a medium for bacterial growth.

Acquired pellicle
It..is acellular film composed of salivary glycoproteins that closely and firmly adheres
to the oral cavity. It is distinct from plaque, which is cellular and loosely adhered
to the teeth until calcified into calculus. Acquired pellicle that become..discolored as a
result of poor oral hygiene is called brown pellicle.

Local predisposing factors

1. Calculus

It consists of mineralized bacterial plaque that

forms on the surfaces of natural teeth and dental
prostheses. There are two types of calculus:
- Supra gingival calculus mostly formed in the

buccal surfaces of the maxillary molars and the lingual surfaces of the mandibular
anterior teeth. Subgingival calculus is usually present on the root surface under the
gingival margin. When the gingival tissues recede, sub gingival calculus becomes
exposed.

Formation of calculus

- It occurs between the 1st and 14th days of plaque formation (starts 4 to 8 hours).
It occurs by calcification and crystallization of plaque from oral fluids.
Saliva supra gingival calculus
Gingival Fluid sub gingival calculus.
- Calcification begins along the inner surface of the plaque.

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 ETIOLOGY OF PERIODONTAL DISEASES ‫ وضاح عبد الناصر نعمان الحاج‬/‫د‬

Etiologic significance of calculus

There are a positive correlation between the presence of calculus and the prevalence
of gingivitis, but this correlation is not as important as that between plaque and
gingivitis. Calculus importance that it is considered as retentive factors for plaque
accumulation.

2. Dental Stains
Dental stains may lead to tissue irritation by creating a rough tooth surface, which
contributes to plaque accumulation and retention.

3. Iatrogenic Factors
Deficiencies in the quality of dental restorations or prostheses are contributing
factors for gingival inflammation and periodontal destruction.

a. Over hanging margins of restorations which play

an obvious role in the retention of plaque (especially
subgingival plaque and make the cleaning is more
difficult.
b. Over contoured crown and restorations also tend
to accumulate plaque possibly prevent the self-
cleaning mechanisms of the adjacent cheek, lips
and tongue.
c. Open contacts: Food particles create a favourable
environment for plaque accumulation. They Act as
a direct mechanical irritant to the tissue.

4. Design of removable partial dentures

The presence of clasp and different designs of them may increase the plaque and food
accumulation. Also the improper design and position of the clasp or denture base may
cause trauma by its impingement on the gingiva and oral mucosa

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 ETIOLOGY OF PERIODONTAL DISEASES ‫ وضاح عبد الناصر نعمان الحاج‬/‫د‬

5. Restoratives dentistry procedures

The instruments and devices used in restorative procedures such as matrix bands
and retainers and rubber dams may cause trauma to periodontal tissues

Rubber dam

Matrix retainer

6. Malocclusion

Malocclusion may cause plaque-induced marginal

gingivitis, gingival enlargement, gingival recession
and chronic periodontitis.

7. Orthodontic Therapy
1- Brackets, bands, wires and other orthodontic
parts act as plaque retentive factors which increase
plaque accumulation and make self-cleansing and
tooth brushing process are more difficult
2- Gingival overgrowth may be associated with
orthodontic therapy

8. Tooth Brush Trauma

Exaggerated brushing technique or use of hard
toothbrush may cause harmful effects on teeth
and oral mucosa.
These effects include: Abrasion of the teeth,
gingival recession and ulceration of the
gingival tissues.

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ETIOLOGY OF PERIODONTAL DISEASES ‫ وضاح عبد الناصر نعمان الحاج‬/‫د‬

9. Tobacco use
The smokers had more sites with:
1-Deep pockets 2- Stains 3-Greater
attachment loss 4- Severe periodontal disease.

Effects of tobacco use

1- Diminish host response and increase disease
susceptibility.
2- Less numbers of T- lymphocytes and less
antibody production and serum levels of IgG
antibobies to Provetella intermedia and Fusobacterium . nucleatum.
3- Diminish neutrophils chemotaxis, phagocytosis or both.
4- Nicotine decrease gingival blood flow.

10. Abnormal habits

1. Unilateral mastication
One side of the mouth is affected by periodontal disease. Mouth in the
nonfunctional side will has loss of tone, accumulation of food and calculus.
2. Abnormal biting habits

It includes pencil biting, nail biting, lip biting, cheek biting etc. These traumatic
injuries affect both periodontium and teeth.

3. Clenching and bruxism

This excessive pressure may cause necrosis of the periodontal membrane.

4. Mouth breathing

Mouth breathing leads to the dehydration of the mucous membrane and lowered
tissue resistance.

11. Food impaction

It is the wedging of food between two teeth because of faulty contact creating a
constant source of irritation leads to the tissue inflammation.

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 ETIOLOGY OF PERIODONTAL DISEASES ‫ وضاح عبد الناصر نعمان الحاج‬/‫د‬

Types of food impaction

1.Vertical: wedging of food between the teeth by occlusal pressure.
2.Horizontal: wedging of food by the action of the cheeks and tongue during the
mastication.

Systemic Predisposing Factors

1. Nutritional Influences (Faulty nutrition)
It includes:
1- Physical character of the diet 2- Effect of nutrition on oral microorganisms
3- Vitamin deficiencies.

1- Physical character of the diet

Soft diets, although nutritionally adequate, may lead to more plaque and calculus
formation. Hard, fibrous foods provide surface cleansing action and stimulation,
which results in less plaque and gingivitis, even if the diet is nutritionally
inadequate.

2- Effect of nutrition on oral microorganisms

Amount and type of carbohydrates in the diet and the frequency of intake can
influence bacterial growth.

3- Dietary deficiency
Dietary deficiency conditions such as vitamins A, B, C (Scurvy), D and E; and
protein deficiency are often responsible in part for the development of periodontal
disease.

Vit. A deficiency: Hyperkeratosis and hyperplasia of the gingiva with a tendency

for increased periodontal pocket formation.
Vit. B deficiency: Gingivitis, glossitis, glossodynia, angular cheilitis, and
inflammation of the entire oral mucosa
Vit. C deficiency :gingival inflammation, bleeding and retardation of wound
healing.
Vit. D deficiency: osteoporosis of alveolar bone, reduction in the width of the
periodontal ligament space, defective calcification and some cementum resorption.

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 ETIOLOGY OF PERIODONTAL DISEASES ‫ وضاح عبد الناصر نعمان الحاج‬/‫د‬

Protein depletion results in anemia, leukopenia, edema, , decreased resistance to

infection, slow wound Healing. So, protein deprivation causes degeneration of the
connective tissue of the gingiva and periodontal ligament, osteoporosis of alveolar
bone, retardation in the deposition of cementum, delayed wound healing, and
atrophy of the tongue epithelium.

2. Debilitating disease
Gastrointestinal disorders, syphilis, nephritis, liver diseases, tuberculosis and other
systemic diseases may show signs in the mouth.

3. Hematologic Disorders
1- In leukemia, the gingival lesion may be described as a symptom of the blood
disease (Bleeding), infection or as infiltration enlargement of gingivae.
2- In thrombocytopenia, there is increase in gingival bleeding due to decrease of
platelets.
3- In leukocytopenia, there is increase of infection

4. Endocrine dysfunction

Miller believed that even mild uniglandular or polyglandular aberrations may

create susceptibility for periodontal inflammation which together with local
etiologic factors could create a periodontal lesion.

a. Diabetes

There is a tendency toward alveolar bone destruction in patients with uncontrolled

diabetes; periodontal abscesses with profuse exudative flow are common. Diabetes
also associated with decreased and defective immune cells functions.
b. Pituitary disorders

In hypopituitarism, crowding of teeth and enlargement of gingival tissues has been

noted. Spacing of the lower teeth due to enlargement of the jaws may occur in
hyperpituitarism.

c. Parathyroid gland disorders

Oral changes include malocclusion and tooth mobility, radiographic evidence of

alveolar osteoporosis

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 ETIOLOGY OF PERIODONTAL DISEASES ‫ وضاح عبد الناصر نعمان الحاج‬/‫د‬

d. Puberty, pregnancy, menustration and contraceptive bills

- Susceptibility to gingival disturbances is more prevalent during puberty,
pregnancy, menustration and contraceptive bills usually because of endocrine
adjustments taking place during these periods.
- Gingival enlargements, colour changes, bleeding, and mulberry like swelling can
be seen. The presence of local factor is important for these changes to occur.
5. Psychogenic factors

People under stress and tension often develop habits antagonistic to the health of
the periodontium such as pencil biting and bruxism. Also, increase in some
hormones like cortisone in response to stress play a role in decrease in immune
cells.

6. Radiation

Radiations of intense dose/higher dose either therapeutic or atomic disturbs the

normal alveolar bone pattern resulting in periodontal destruction and ulcerative
lesion. Radiation also causes atrophic changes in salivary glands which cause
xerostomia which has deleterious effects on oral and gingival tissues.

7. Immunodeficiency disorders
Deficiencies in host defense mechanisms may lead to severely destructive
periodontal lesions. These deficiencies may be primary, or inherited; or secondary,
caused by immunosuppressive drug therapy (Corticosteroids and cyclosporin) or
pathologic destruction of the lymphoid system. Leukemia, Hodgkin's disease,
lymphomas, and multiple myeloma all may result in secondary immunodeficiency
disorders. Some diseases also cause the same symptoms such as AIDS.

8. Medications
1- Gingival overgrowth:

Phenytoin “Delantin Na” (Antiepileptic) - Cyclosporin (Immunosuppressive) –

Nephedipine (Antihypertensive)

2- Gingival inflammation and desquamation

Contraceptive drugs – Bisphosphonates.

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