U P D A T I N G N G O F T H E B A S I C O R A L C A R E N O T E B O O K 2 0 1 2F O U S P - M I N I S T R Y O F H E A L T H , B R A Z I L

UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 - FOUSP - Ministry of Health 1

Periodontal Disease

1. Conceptual and Epidemiological Aspects

! Periodontal disease should be seen as an unbalanced process between the actions of aggression and defense in the protective and supporting tissues of the tooth. The principal determinant is the bacterial biofilm (biofilm is a microbial consortium included in the ECP mass [extracellular polysaccharides] resulting from binding, multiplication and development of microorganisms on solid surfaces – substrate – in water e n v i r o n m e n t h t t p : / /www.farmaconline.ufg.br in Nov 2012. Substrate in ecology refers to the surface, sediment, base, environment or any other surface

that may support living organisms. Wikipedia in Nov 2012) and the different responses given by the host. It is no longer considered a slow and continuous progression but it can exhibit variable progressive standards. It is understood as an infectious disease where alterations in shape and function are considered signs. The normal periodontium is defined by

biological variables consistent with the d i s e a s e ’ s etiopathogenesis that allows patients who once were diseased and presented sequels such as recession and mobility, to return to a healthy periodontal

condition. Today, periodontal disease is an important risk factor to low weight preterm labor, diabetes, vascular and cardiac diseases.

In Brazil, the percentage of people with periodontal problems in the age groups from 15 to 19, 35 to 44 and 65 to 74 is 53.8%, 78.1% e 92.1% respectively, according to the results of the SB Brazil 2003 Epidemiological Survey.

Periodontal disease should be seen as an unbalanced process between the actions of aggression and defense in the protective and supporting tissues of the tooth.

1. Conceptual and Epidemiological Aspects

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2. Principal Risk Factors

Page 2

3. Collective Approach

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4. Individual Approacha. Gingivitis

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b. Periodontitis

Pages 3 e 4

7. Credits

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CHAPTERS UPDATING AND ILUSTRATING

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5. Prevention

6. Clinical case

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2. Principal Risk Factors•Cultural, social and economic factors.

• Diabetes.• Smoking. • Lack of biofilm control.

3. Collective Approach•Organizing actions such as surveillance of the risk signs in oral health: social risk, no access to brushing, bleeding/gingival secretion, diabetes mellitus, immunosuppression and smoking.

• Actions to promote health (educational and interrelated actions) principally associated to the groups that provide care to diabetes mellitus, smoking, pregnancy, among others.

4. Individual Approach! It is important to have a total approach in the treatment of periodontal disease involving the actions of health promotion and prevention (to control the disease activity and its risk factors) and surgical rehabilitating treatment that is increasingly becoming a rare procedure due to the possibility of solving the cause. This means addressing the causes of the disease, not only its consequences in order to impact the health/disease process.

! Two classical ways are described as manifestations of the health/periodontal disease process: gingivitis and periodontitis.

! With the evolution in the concept of understanding periodontal diseases, it was concluded that gingivitis and periodontitis are independent processes, that is, gingivitis does not necessarily evolve to periodontitis but gingivitis is an important risk factor to periodontitis.

a. Gingivitis! Gingivitis is an inflammatory manifestation of the marginal gingiva triggered by the accumulation of supragingival bacterial plaque and the breakdown of the aggression/defense balance. It is an inflammatory process that must be prevented and treated.

Diagnosis

•To diagnose gingivitis, it is important:

•Plaque control evaluation

•Bleeding evaluation

•Woman’s health evaluation

•Evaluation of systemic alterations or smoking that may be influencing the periodontal condition.

Treatment

Treatment can be performed in many weekly individual or collective visits. Their number will depend on the disease control.

• Removal or treatment of biofilm retention factors.

• Professional supragingival scaling and polishing.

• Educational actions for biofilm control.

• Use of biofilm chemical control (only when necessary and for a limited time).

• Monitoring and control of risk factors such as diabetes, pregnancy, hormonal alterations, among others. If gingivitis is related to systemic factors or

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medications, the possibility of intervention in these factors should be evaluated.

• Treatment progress should be assessed by the biofilm control and the disease’s activity. The patients may be discharged if there is no gingival bleeding and a minimum amount of biofilm compatible to their periodontal health condition.

Maintenance

! To maintain periodontal health, the frequency of recalls varies individually according to the risk, gingival bleeding and biofilm control.

b. Periodontitis! The inflammatory conditions present in gingivitis cause a virulent subgingival bacterial biofilm responsible for inflammation of the supporting tissues.

! Periodontitis is a group of diseases that characterizes for inflammation of the supporting tissues and teeth’s protection, followed by loss of connective tissue attachment. This is a consequence of the aggression caused by the subgingival bacterial biofilm.

! Chronic periodontitis is slow and the most prevalent type. Attachment loss is associated to oral hygiene standards and risk factors. Aggressive periodontitis is rare but fast, presenting high dental morbidity and mortality. These periodontitis have a genetic component that is important in preventing them.

Diagnosis

!

! It is connected to the evaluation of active disease, the type of progression and causal and modifying factors:

• Establishment of the disease activity: defined by attachment loss and inflammatory signs (bleeding and secretion).

• Biofilm control evaluation.

• Evaluation of systemic conditions, smoking and aspects of social and economical risk and medications use.

Treatment

!

! Periodontal health maintenance and treatment success basically depend on the ability of controlling the biofilm by the user/professional binomial and risk factors.

Control, mainly smoking and diabetes.

Treatment will basically consist of actions connected to DISEASE CONTROL PHASE, and a PHASE OF TREATING THE CLINICAL MANIFESTATIONS:

• Treatment of Gingivitis as previously described, including the educational actions.

• Treatment of Periodontitis by means of controlling the subgingival biofilm, scaling and subgingival planning. These procedures do not depend on depth and should always be done as a first option. If periodontitis is related to systemic factors or noxious habits the possibility of intervention should be considered.

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References

! If Periodontitis is chronic and slow, the cases where subgingival scaling failed should be referred to surgery. Special attention must be given to the evaluation of the failure cause, because many times the patient’s lack of controlling the biofilm is the main reason of failure and this should be the principal focus of professional care.

Periodontal Therapy Monitoring

! Treatment may last several weekly visits that can be individual or in group. The number will depend on the disease’s control.

! At short term monitoring, treat the inflammatory signs and at long term the lack of progression in attachment loss.

! Clinical discharge must be given to the users when they have no signs of disease activity and present adequate plaque control.

Rehabilitation

! The surgical, restorative or rehabilitating procedures necessary to reestablish esthetics, shape and function impaired by the disease.

5. Prevention! To prevent periodontal problems just the individual to use dental floss and toothbrush in accordance with a correct technique of handling. !

6. Clinical case

The patient presented gingival inflammation (note the color red-blue gum) and prostheses with marginal excess. Initial procedure: orientation for oral hygiene and removal of marginal excess.

!

!

Return after 7 days: note the color change of the gums (pale pink) and consequent desinflamation of the gum.

6. Credits

Updating of the Primary Oral Care Notebook 2012 - FOUSP - Ministry of Health: images and glossary:

Prof. Dr. Cláudio Pannuti – FOUSP

Dr. Marco Antonio Kulik - FOUSP (imagem gengivite e pediodontite)

Dr. André Hespanhol - FOSUP (imagem conceitos epidemiológicos)

Profa. Dra. Mary caroline Skelton-Macedo - FOUSP