iatrogenic factors in periodontitis, biological width violation, endo perio, perio prostho

1. IATROGENIC
FACTORS AFFECTING
PERIODONTIUM
Hrishi T S

3. Careless therapeutic procedures ,Injudicious use of
instruments &chemicals, Improper treatment planning and negligence
cause traumatic injuries to periodontium
supporting tissues must be always maintained in a state of health for
proper function
Injuries induced by the dentist can severly impair the periodontium
and other oral structures leading to morbidity of patient
INTRODUCTION

4. SO the dentist should inculcate thorough knowledge and
expertise to “do no harm” to the patient

5. iatros • physician
gennan • To produce
Iatrogenic- means…

6. IATROGENIC DISEASE
Disease that has been induced by the physicians' activity,
manner, or therapy, and this term is usually used for an
infection or other complications of treatment.
IATROGENIC FACTORS IN DENTISTRY
Inadequate dental procedures that contribute to the
deterioration of the periodontal tissues.

7.  Restorative
 Endodontic
 Prosthodontic
 Orthodontic
 Exodontia
 Periodontal
Causative factors

8. Restorative factors
Marginal periodontium Fields of Restorative Dentistry &
Periodontics overlap

9. Restorative Factors
♣Violation of Biologic Width
♣ Morphologic Features of Restorations
♣ Restorative materials
♣ Direct injury to the Periodontium

10. Biologic width and its Violation

11. The biologic width is
defined as the dimension of
the soft tissue, which is
attached to the portion of
the tooth coronal to the
crest of the alveolar bone.
tissue occupying the area
between the base of the
gingival sulcus and alveolar
crest

12. † Gargiulo et al. (1961)
287 individual teeth from 30 autopsy specimens
Definite proportional relationship between the alveolar crest, the
connective tissue attachment, the epithelial attachment, and the
sulcus depth
Mean dimensions:
sulcus depth - 0.69mm,
epithelial attachment -0.97mm,
connective tissue attachment -1.07mm.
biologic width- 2.04mm

13. Vacek et al. (1994)
Reported similar biologic width
dimensions
Observed mean measurements
• 1.34mm for sulcus depth
• 1.14 for epithelial attachment,
• 0.77mm for connective tissue
attachment
biological width of 0.75- 4.3 mm

14. Biologic width evaluation
Radiographic – not diagnostic- due to superimposition
Sounding to bone

15. A minimum of 3mm was required from the restorative
margin to the alveolar crest to permit adequate healing
of periodontium following restoration of the tooth.
Ingber et al(1977)
This allows for adequate biological width when
restoration is placed 0.5 mm within gingival sulcus

16. INFLAMMATION
VILOLATION
OF BIOLOGIC
WIDTH
BONE LOSS ATTACHMENT
LOSS
periodontal pockets gingival recession

17. Violation of Biological Width
Unpredictable bone Loss
Gingival Recession
Persistence of gingivitis
Body attempts to recreate the biological width

18. Correction of Biologic Width Violations
Surgical Crown Lengthening to remove bone away from
the restorative margin
Orthodontic extrusion of tooth

19. Surgical crown lengthening
Gingivectomy
• adequate attached gingiva and more than 3mm of soft
tissue coronal to the bone crest
Flap surgery +bone contouring
• Inadequate attached gingiva and less than 3mm of soft
tissue.
• The bone removed by measuring distance of the
biologic width + 0.5 mm as safety zone

20. Orthodontic extrusion
Low orthodontic extrusion forces
Tooth will erupt slowly bringing
the alveolar bone & gingival
tissue with it till
ideal level
Surgical correction of the bone
and gingival level
Rapid orthodontic extrusion
Tooth is erupted to desired amount in
several weeks
Supracrestal fibrotomy performed weekly
in an effort to prevent the bone and tissue
from following the tooth
The tooth is stabilized for 12 weeks

21. Margins of Restoration
• unaesthetic
• Well tolerated
Supragingival
margins
• Earlier thought to retain plaque
• Well polished restorations are well
tolerated
Equigingival
margins
• Not accessible for cleaning and polishing
• Placed far below can violate biologic width
Sub gingival
margins

22. Guidelines for placement of margins using sulcus depth as a
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- Gingivectomy performed to reduce
the depth to 1.5mm

23. Effect of subgingival margins
Large amount of plaque
More severe gingivitis
Greater loss of attachment & recession, Deeper pockets
Increase rate of GCF flow
(Waerhaug 1978, Silness 1980, Orkin 1987)

24. Subgingival zone is composed of the
• Margin of the restoration
• The luting material
• Prepared and unprepared tooth surface

25. Marginal roughness can contribute to plaque accumulation
Improper marginal
fit
sources
Separation of the restoration
margin and luting material
Dissolution and disintegration
of the luting material

26. Subgingival margins typically have a gap of 20 to
40 μm between the margins of the restoration and
unprepared tooth
Colonization of this gap by bacterial plaque contributes to the
detrimental effect of margins placed in a subgingival
environment

27. Orkin et al. (1987) demonstrated that subgingival restorations
had a greater chance of bleeding and exhibiting gingival
recession than supragingival restorations.
Supragingival position of the crown margin was the most
favorable, whereas margins below the gingival margin
significantly compromised gingival health

28. Waerhaug (1978) stated that subgingival restorations are
plaque-retentive areas that are inaccessible to scaling
instruments
Stetler & Bissada (1987) -Teeth with subgingival
restorations and narrow zones of keratinized gingiva showed
significantly higher gingival index scores than teeth with
submarginal restorations with wide zones of keratinized
gingiva

29. Factors determining location of restorative margins:
 esthetics
 retentive factors
 susceptibility to root caries, and
 degree of gingival recession.
Prudent to place restorative margins supragingivally if :
 Esthetic
 increased retention form
 preexisting margins
 root caries
 cervical abrasion
 Root Sensitivity
Not a concern

30. MORPHOLOGIC
CHARACTERISTICS

31. Overhangs
An extension of restorative material beyond the
confines of a cavity preparation
RESTORATIVE OVER HANGS

32. Overhanging dental restorations a contributing
factor to gingivitis and possible periodontal
attachment loss
prevalence estimated at 25–76% for all
restored surfaces (Brunsvold & Lane1990)
overhanging restorations contribute to gingival inflammation
due to their retentive capacity for bacterial plaque
)

33.  Jeffcoat and Howell (1980) demonstrated a link to
the severity of the overhang and the amount of
periodontal destruction
 with overhangs, the flora changed from gingival
health to one of chronic periodontitis with
increase in black pigmented bacteriodes Lang et
al. (1983)

34. Highly significant association b/w bone loss and
overhanging restoration Hakkaranein & Ainamo 1997
Removal of overhangs permits more effective control of
plaque and reduction of inflammation and small increase in
bone height Jeffcoat & Howell ( 1980) )

35. Mechanism by which overhangs cause
periodontal destruction
 promote the retention of plaque
 complicate plaque control
 Increase in the specific periodontal pathogens
 Impinge on the interproximal embrasure space
Displacement of gingiva & violation of biologic width

36. overhanging restorations can be recontoured without replacing the restoration
should be considered a standard component of
nonsurgical treatment
Diamond burs Diamond strips

37. Prevention
Use of wedges and proper adaptation of matrix bands

38. Contour and Contacts
Undercontouring
Overcontouring plaque retentive no
self cleansing effect in ginival third
Overcontouring can occur in
• Interdental Areas
• Buccolingual Aspect
• Furcation Aspects
Overcontoured restoration forming a plaque trap

39. Interproximal contact areas are commonly
overcontoured
The proximal contacts determine
• Marginal ridge relationships
• Occlusal embrasure form
• Buccal and lingual embrasure form,

40. 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

41. Overcontouring leads to
Collection of debris
 Inflammation
 Hyperplasia
 Engorgement of marginal gingiva
 Decreased keratinization
 Deterioration of gingival fibers
greater the amount of facial and lingual bulge of an
artificial crown, the more the plaque retained at the
cervical margin. Yuodelis et al. (1973)

42. buccal and lingual crown contours should be ‘‘flat’’,
not ‘‘fat
furcation areas should be ‘‘fluted’’ or ‘‘barreled out’
Becker & Kaldahl (1981)

43. Overcontouring of exposed furcation region
Formation of a horizontal triangular region
by roots & cervical bulge
Plaque accumulation
Furcation Region
Periodontal breakdown

44. CONTACTS
 loose or open proximal contacts –contributing factors to
periodontal pocket formation
 greater food impaction at sites with open or loose
contacts

45. Literature proposes conflicting views
No difference in periodontal breakdown at sites with
deficient proximal contacts compared to satisfactory
sites Kepic & O’Leary (1978) Hancock et al (1980)

46. Occlusal view of normal buccolingual
width and position of interdental contact
 Excessively wide contacts obliterates
interdental embrasure
 Hyperplastic bulging of interdental
papilla

47. Interdental contacts if placed too high
occlusally
Eliminate the marginal ridge & reduce
sufficient area of contact
Food Impaction

48. Buccal view of excessive
occlusogingival extent of
interdental contact, which also
obliterates essential interdental
embrasure

49. normal position and size of
proximal contact creating a slight
col
Interdental view of abnormally widened
proximal contact,
Resulting in exaggerated col formation
that is subject to breakdown.

50.  Broadened proximal contacts constrict both
occlusal and interdental embrasures.
 Difficult to clean the interdental area
Characteristic changes of interdental tissue
• Facial and lingual hyperplasia of interdental
papilla
• Exaggerated col formation
• Microbial invasion
• Inflammation and edema
• Osseous involvement

51. Excessively narrow interdental & lack of contact
food impaction and retention tooth drifting
marginal ridge discrepancy and bone loss

52. Occlusal Morphology of
Restoration
Increased Buccolingual Width of
Occlusal Table
More axial stress
transmitted to
periodontium with
wide occlusal table
than narrow
Greater incidence of
cross- arch & cross
tooth balancing
interferences during
lateral excursive forces

53. • Obliteration of natural sluiceways
• Improper passage of food from the occlusal
table
• Food being forced into the contact area

54. Tooth with high
filling , painful
Patient forced to
acquire a diff.
relationship of
maxilla to mandible
Puts many other
teeth into traumatic
functional
relationship
TMJ problems
HIGH POINTS

55. Overcarving of
occlusal anatomy
to remove centric
holding areas
erupt in new occlusal
relationship
Traumatic to the
periodontium
during
functional and
parafunctional
excursive
movements
CARVING

56. Material
restorative materials are not themselves injurious
exception - self-curing acrylics
surface of restorations should be as smooth as
possible to limit plaque accumulation
Crown & bridge cements cause
irritation

57. Non- precious alloys Inflammatory gingival response
Pierce LH, GoodkinRJ, 1989
Nickel – allergic reaction in 9% of people
Case of alveolar bone loss after the placement of crowns with a
high nickel content has been reported( Bruce GJ, Hall WB 1995)

58. Surface Roughness
☻Tissue respond more to surface roughness than
composition of material
☻Roughness of intra-oral surfaces increase in plaque
retention .They protect bacteria against shear forces
☻all restorative materials placed in the gingival
environment should have the highest possible degree of
polish.

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

60.  Rough surfaces accumulate and retain more plaque,
 It is less obvious when optimal oral hygiene
Increased proportion of motile organisms and spirochetes
Inflamed periodontium,
↑ bleeding index, ↑GCF

61. Procedures that Increase Roughness
• Polishing paste on restorative material
• Application of fluoride gel on porcelain
• Application of fluoride gel (pH<5) or gels
containing hydrofluoric acid on titanium implants
• Air powder abrasive systems on all materials

62. Subgingival Debris
Subgingival debris can be left during-
 Use of retraction cord
 Impression material
 Provisional material
 Cement
Examining the sulcus with explorer, remove the foreign
bodies

63. INJURY TO THE PERIODONTIUM BY
RESTORATIVE PROCEDURES

64. Application of Rubber Dam and Matrix
Placed too subgingivally Stripping of junctional epithelium
and gingival connective tissue
attachment
Placed for too long Ischemia to the degree that
sloughing of tissue and subsequent
gingival recession

65. Laceration
of the
gingival
margin
Inflammatory
Cavity and Crown
Preparation
gingival
margins
Injury in the
region of
inadequate
attached
gingiva
GINGIVAL
RECESSION

66. 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

68. Improper placement of matrix band and wedge
result in poor contour
Food lodgment and plaque accumulation

69. Impressions
 retraction cords are used to displace the free
gingival tissues
 . May cause damage to subgingival tissue.
(Usually reversible)
 injudicious use of gingival-retraction techniques
can injure the soft tissues and cause permanent
alterations, such as recession.

70. Dry retraction cords cause stripping of junctional & sulcular
epithelium while removal
Retraction cords impregnated with chemicals- chemical burns
Chemical burn Retraction cord soaked with ferric sulfate,

71. • Electrosurgical retraction recession & loss
of attachment
• Not indicated in regions of inflammation or of
extremely thin gingival tissue

72. misuse can cause extensive damage
Gingival recession and sequestration of
bone after electrosurgery
Electrosurgical burn on the palatal aspect of
the maxillary left canine

73. Retained elastic impression materials, within periodontal
tissues after removing impression can lead to massive
loss of attachments

74. Provisional Restorations
If made in haste or without consideration - permanent
damage to periodontium
Critical areas include
 The marginal fit
 The contour
 The surface finish

75. Overextended
Temporary Crowns
• Gingival
alterations in
interdental, facial
and lingual
marginal region
• Hyperplasia or
recession if
attachment is
injured severely
Underextended
Temporary Crowns
• Not as serious as
overextension
• Hypersensitivity,
interfering with
adequate oral
hygiene measures
Poor proximal-contact
relationships
• Food impaction
and retention
• Drifting of the
approximating
teeth
Rough or Porous
Surface Finish
• Difficult to
maintain good oral
hygiene
• Plaque
accumulation
• Inflammation
• Recession

76. ENDODONTIC PROCEDURES

77. Root perforations
Frequency - 3 to 10%
Artificial communication b/w root canal system and
supporting periodontium

78. Root perforations occur during
 Access cavity preparation
 Root canal preparation
 Post space preparation
Location
 Cervical
 Midroot
 Apical

79. Prognosis
₯ Location of perforation- most imp
₯Time lapse b/w occurrence & treatment
₯ Size of the perforation

80. Crestal root perforations - most susceptible to epithelial
migrations & rapid pocket formation
Perforations in furcation areas - because of
proximity to epithelial attachment-secondary
periodontal involvement

81. If the perforation is located
close to the gingival
sulcus- periodontal pocket
Bacterial infection
following perforation
Exacerbation of a
preexisting periodontal
lesion -development of
clinical symptoms similar
to those of a periodontal
abscess
Down growth of
epithelium, inflammation ,
bone resorption and
necrosis can result
Obturation of defects with
gutta-percha- poor seal
and subsequent bacterial
inflammation of
periodontal tissues

82. VERTICAL ROOT FRACTURES
CAUSES
• preparation of canal for post
• Increased compaction pressure during
obturation of root canal
• Improper selection of post
• Expansion of posts and pins due to
corrosion

83. DIAGNOSIS
Radiographs show typical ‘J shaped
‘radiolucency
Wide space adjacent to the obturated canal
Deep narrow isloated pocket depth
COMPLICATIONS
Inflammation due to plaque accumulation
abscess
Fistulas
Osseous defects

84. PROSTHODONTIC PROCEDURES

85.  Prosthesis are susceptible for plaque formation
 inflammatory tissue reactions of mucosa covering
alveolar ridge can occur in response to bridge pontics

86. Pontic Designs
• Pontic should have a occlusal surface that Stabilizes the
opposing teeth
• Allows for normal mastication
• Doesn't overload the abutment teeth
• Occlusal table need not be buccolingually narrower than
those of the abutment teeth.

87. Manner in which pontic is designed & adapted to
edentulous ridge determines health of the surrounding
tissues
Concavities on tissue surfaces plaque trap
bacterial accumulation inflammation of
adjacent tissues

88. Sanitary
Tissue surface
3 mm away
from ridge
Ridge lap
Tissue surface
straddles the
ridge like a
saddle
Modified
ridgelap
Tissue surface
on facial side
concave
OVATE
Tissue surface is
convex- fits into
receptor site

89. RIDGE-LAP
-Least desirable periodontally
- Difficult plaque control
SANITARY
-Easiest access for
hygeine procedure
-Unesthetic form
Pontic design
MODIFIED RIDGE- LAP
-More open lingual form
- Better access for hygiene
OVATE
-Ideal pontic design
- Easy to clean
- Esthetically satisfactory

90. Excessive contact of
pontic with ridge
Causes initial
blanching
Bone resorption
Scraping of
edentulous
cast for
positive
contact
Atrophy of
underlying
bone
Periodontal
involvement of
abutment teeth

91. Severely tilted
abutments
Deep
psuedopocket
on mesial
aspect of such
teeth
periodontal
breakdown

92. Removable Partial Denture
RPD increased gingivitis, periodontitis & abutment
motility
FACTORS ATTRIBUTED TO PDL BREAKDOWN
 Plaque Formation & oral hygiene
 Coverage of marginal gingiva by parts of RPD
 Occlusal forces transmitted to the remaining teeth & their
periodontal tissues by the prosthesis

93. Gingival responses to various types of removable partial dentures
(Bissad et al, 1974 )
Gingival health was adversely affected by RPD
Degree varied based on denture gingival relationship
Severe pathologic changes occurred in areas without
relief
Metallic bases elicited less response

94. Plaque formation and oral hygiene
Increase plaque accumulation on tooth surface in direct
contact with dentures & teeth in opposing arch.
(El ghamrawy , 1976)
 the microbial composition of dental plaque
developing on fifteen abutment teeth
 removable partial dentures favored a
proliferation of spiral organisms.

95. McHenry et al 1992 The Journal of Prosthetic Dentistry Vol 68, Issue 5, Pages 799–803
evaluated the effect of a removable partial denture mandibular
major connector design on the surrounding gingival tissues
Framework designs like Lingual plate contribute to ↑ plaque and
altered bacterial flora

96. Occlusal Forces Transmitted To Remaining Teeth
& Their Periodontal Tissues
Occlusal forces transmitted to abutment teeth by RPDs -
Jiggling as well as orthodontic component esp. in distal
extension RPD
Magnitude, direction & frequency of force vary among
patients and sites

97. Increased mobility of the abutment teeth ( Rissin et al 1979)
Good alveolar bone support
Good plaque control
Periodic recall visits
No PDL breakdown
Bergman et al 1982
Carlsson et al 1965
poor patient co-operation
Long recall interval
Gingivitis
Pocket deepening
Mobility

98. Rissin et al. (1985) The Journal of Prosthetic Dentistry
Compared abutment teeth of patients with RPDs, FPDs and
no prosthesis
RPD wearers - greatest plaque and calculus deposition,
probing depth & alveolar bone loss

99. Zlataric et al. (2002)
In an evaluation of 205 patients with RPDs, abutment teeth
showed more disease than non abutment with
↑Plaque index,
↑Gingival index,
↑ Probing depth
↑ Tooth mobility
↑ Gingival recession

100. Improperly designed clasps lead to excessive stresses &
occlusal traumatism and damage abutment teeth
During settling of posterior RPD ,clasp arm may
impinge on marginal tissue- if not supported by rests

101. Acrylic non-rigid material whose strength is improved
by ↑ the thickness
Bulky dentures more potential to damage soft tissues
Acrylic Partial Denture

102. Cause periodontal damage by
 Physical stripping of gingiva
 Damaging lateral forces
 Increased plaque accumulation

103. Orthodontic Therapy

104. The periodontal reaction toward orthodontic appliances depends
on multiple factors
 host resistance
 the presence of systemic conditions and
 the amount and composition of dental plaque.

105. Orthodontic fixed appliances induce an increase in the
volume of dental plaque
cause a shift in the type of bacteria (Petti et al 1997).
Direct trauma to supporting tissue

106. INTERFERENCE WITH PLAQUE CONTROL
 Plaque - inflammation –gingivitis
 Appliance per se causes plaque accumulation
 Inability of the pt to adequately clean

107. Effect of orthodontic band
Main short term effects
gingivitis & gingival enlargement
Improved within 48 hrs of removal of band
(Baer and Coccaro 1964)
Gingival enlargement ↑ probing depth
 May be due to Trapped plaque
 Mechanical irritation caused by band or cement

108.  Mechanical irritation can be caused by bands by contact
with gingival margins .
 Chemical irritation by exposed cement at margin
 Greater likelihood of food impaction in posterior
between arch wire & soft tissue

109. Microbiology &Orthodontic Band

110. Petti S et al 1997
 Evaluated Microbiological and clinical changes
occurring during the first six months of
orthodontic therapy with fixed and removable
appliances
 15 with fixed and 15 with removable appliances
 Patients with fixed appliances counts, motile
rods, subgingival spirochetes and a of Gram
positive cocci.

111. in patient with removable appliances supragingival motile rods
and subgingival spirochetes
Van Gastel et al., 2007 fixed orthodontic
treatment may result in
localized gingivitis,
which rarely progresses
to periodontitis

112. • Adolescents -fixed therapy
cause Loss of attachment of
1- 2mm
Alstad &
Zachrisson 1979
• Higher prevalence of root
Trossello & resorption
Gianelly 1979
• Failed to show any
significant changes in adult Polson et al.
1988

113. Orthodontic Elastics &
Separators
Injudicious use rapid and severe periodontal
destruction
Elastic below height of contour has a Tendency to slip
apically
Danger of elastics slipping beneath the marginal gingiva &
detaching PDL – mentioned as early as 1870 by McQuillen

114. Band Placement
Stripping of junctional
epithelium. Extrusion
of cement into soft
tissue -acute gingival
or periodontal abscess
Forced Eruption of
Impacted Teeth
Use of banded attachments
& removal of excessive
bone negative impact .
It compromise pdl
attachment of adj teeth

115. Occlusal Consideration
 Orthodontic movement - Unavoidable occlusal
traumatism - Affect health of periodontium
 Disturbance of occlusion produces, although
temporarily- Jiggling type of forces

116. Root resorption
Ottolengui (1914), related root resorption directly to
orthodontic treatment
In 1927 root resorption was a subject of major concern to the
orthodontic field.
Katcham, demonstrated, with radiographic evidence, the
differences between root shape before and after orthodontic
treatment

117. The etiology of root resorption still remains unclear and
is complex, including genetic predisposition and
environmental factors Abass and Hartsfield, 2007

119. Types
• Cementum or surface resorption with remodeling.
• Dentinal resorption with repair (deep resorption)-The
final shape of the root may or may not be identical to
original form.
• Circumferential apical root resorption-root shortening is
evident

120. Movements of roots outside the confines of alveolar process
- development of mucogingival problems esp in areas of thin
bone & gingiva

121. Forces during
frontal & lateral
expansion of teeth
• Development of
tension in
marginal tissues
Stretching
• thinning of the
soft tissues
If expansion
• bone dehiscence • Development of
soft tissue
recessions in
presence of
bacterial plaque
&/or mechanical
trauma like
improper brushing

122. EXODONTIC PROCEDURES

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

124. Procedures 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

125. 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

126. Also the incorrectly positioned band of gingiva becomes non-functional
leading to exaggerated free gingival margin
Situation is esp serious if the original zone of attached gingiva
in the vicinity is minimal

127. Creation of vertical defects distal to 2nd molar
Impacted 3rd Molar extraction

128. Kugelberg et al. (1985)-
Retrospective study -215 patients 2yr after surgery
43.3%- probing depth > 7mm
32.1%- probing depth > 4mm

129. Kugelberg (1990)
evaluated Periodontal healing after 2 & 4 yrs in 51 cases
2yrs post operatively
 16.7% ≤ 25 yrs – intrabony defect more than 4mm
 40. 7%≥ 25 yrs- intrabony defects more than 4mm
4yrs post operatively
 4.2 % ≤ 25 yrs – intrabony defect more than 4mm
 44.4 %≥ 25 yrs- intrabony defects more than 4mm

130. Javier Montero et al 2011
The periodontal health of the second molar was found to
improve gradually after third molar surgery
Probing depth was gradually reduced by about 0.6 mm
quarterly, until a final depth of 2.6 was attained.

131. PERIODONTAL PROCEDURES

132. Calculus maybe dislodged and pushed into the soft tissue
during scaling
Inadequate scaling calculus to remain in the deepest
pocket area
Resolution of the inflammation at the coronal pocket area
Occlude the normal drainage

133. • Trauma to the
Polishing marginal gingiva
Brush
• Generated heat may
cause thermal damage
leading to pulpitis Polishing
cup

134. 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

135. Case reports Burns due to elect cautery unit

136. Burn injury caused by heated ultrasonic scaler

137. Treatment of food impaction with a cold cure acrylic appliance resulting
in chemical burn and pathologic changes in periodontium

138. The traumatic injury of the acrylic plate of
the pendulum appliance
Accidental contact of cheek and alveolar
mucosa with formocresol
Severe ulceration of cheek mucosa due to irritation of molar tube.

139. Severe periodontal damage by an ultrasonic endodontic
device
 Overheating of a maxillary
central incisor caused
 necrosis of soft tissue and bone
on the facial and mesial aspects
 inflammatory response in the
adjacent nasal cavity
 Patient chose to get
her teeth extracted

140. MISSING STRATEGIC TEETH AND THEIR NON
REPLACEMENT
Replacement of strategic teeth is often
overlooked in dental practice
Unreplaced missing teeth Drifting
of adjacent teeth &create conditions that lead to
periodontal disease
Initial tooth movement can be aggravated by
loss of periodontal support

141. Flaring of anterior teeth due to usage of anterior for chewing

142. Sinus Expansion Destroying Bone -MissingUpper Teeth
the sinus expand and destroy bone from the “inside out.”
Headaches from Missing Teeth

143. Failure to Replace First Molars
 Tilting of 2nd & 3rd molar causing decreased
vertical dimension
 Mandibular incisors tilt or drift lingually
 Premolars move distally, lose their intercuspating
relationship with maxillary teeth and may tilt distally

144.  Increased anterior overbite. Mandibular incisors strike
maxillary incisors & may traumatize the gingiva
 Maxillary incisors - pushed labially & laterally
 Anterior teeth extrude due to loss of incisal apposition
 Formation of midline diastema

145. Sequale of non replacement of first molar

146. CONCLUSION
Iatrogenic factors play a considerable role in
periododontal diseases.When treating the patients
objectives of dentists must be clear ,to avoid any
undesirable outcomes of treatment. There is a need
to increase awareness among dental practitioners
about the role of iatrogenic factors in order to get
successful outcome of any dental therapy, which
unfortunately is ignored for a long time.