IATROGENIC

FACTORS AFFECTING

PERIODONTIUM

Hrishi T S

INTRODUCTION

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

SO the dentist should inculcate thorough knowledge and

expertise to “do no harm” to the patient

Iatrogenic- means…

iatros • physician

gennan • To produce

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.

Causative factors

Restorative

Endodontic

Prosthodontic

Orthodontic

Exodontia

Periodontal

Restorative factors

Marginal periodontium Fields of Restorative Dentistry &

Periodontics overlap

Restorative Factors

♣Violation of Biologic Width

♣Morphologic Features of Restorations

♣Restorative materials

♣Direct injury to the Periodontium

Biologic width and its Violation

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

† 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

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

Biologic width evaluation

Radiographic – not diagnostic- due to superimposition

Sounding to bone

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

VILOLATION OF BIOLOGIC

WIDTH

INFLAMMATION

BONE LOSSATTACHMENT

LOSS

periodontal pockets gingival recession

Violation of Biological Width

Unpredictable bone Loss

Gingival Recession

Body attempts to recreate the biological width

Persistence of gingivitis

Correction of Biologic Width Violations

Surgical Crown Lengthening to remove bone away from

the restorative margin

Orthodontic extrusion of tooth

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

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

• unaesthetic

• Well tolerated

Supragingivalmargins

• Earlier thought to retain plaque

• Well polished restorations are well tolerated

Equigingivalmargins

• Not accessible for cleaning and polishing

• Placed far below can violate biologic width

Sub gingival margins

Margins of Restoration

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

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)

Subgingival zone is composed of the

• Margin of the restoration

• The luting material

• Prepared and unprepared tooth surface

Marginal roughness can contribute to plaque accumulation

sources

Improper marginal fit

Separation of the restoration margin and luting material

Dissolution and disintegration of the luting material

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

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

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

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

MORPHOLOGIC

CHARACTERISTICS

Overhangs

An extension of restorative material beyond the

confines of a cavity preparation

RESTORATIVE OVER HANGS

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

)

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)

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) )

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

overhanging restorations can be recontoured without replacing the restoration

should be considered a standard component of

nonsurgical treatment

Diamond burs Diamond strips

Prevention

Use of wedges and proper adaptation of matrix bands

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

Interproximal contact areas are commonly

overcontoured

The proximal contacts determine

• Marginal ridge relationships

• Occlusal embrasure form

• Buccal and lingual embrasure form,

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

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)

buccal and lingual crown contours should be ‘‘flat’’,

not ‘‘fat

furcation areas should be ‘‘fluted’’ or ‘‘barreled out’

Becker & Kaldahl (1981)

Furcation Region

Overcontouring of exposed furcation region

Formation of a horizontal triangular region by roots & cervical bulge

Plaque accumulation

Periodontal breakdown

CONTACTS

loose or open proximal contacts –contributing factors to

periodontal pocket formation

greater food impaction at sites with open or loose

contacts

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)

Occlusal view of normal buccolingual

width and position of interdental contact

Excessively wide contacts obliterates

interdental embrasure

Hyperplastic bulging of interdental

papilla

Interdental contacts if placed too high

occlusally

Eliminate the marginal ridge & reduce

sufficient area of contact

Food Impaction

Buccal view of excessive

occlusogingival extent of

interdental contact, which also

obliterates essential interdental

embrasure

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.

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

Excessively narrow interdental & lack of contact

food impaction and retention tooth drifting

marginal ridge discrepancy and bone loss

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

• Obliteration of natural sluiceways

• Improper passage of food from the occlusaltable

• Food being forced into the contact area

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

Overcarving of occlusal anatomy to remove centric

holding areas

erupt in new occlusalrelationship

Traumatic to the periodontium

during functional and parafunctional

excursive movements

CARVING

Materialrestorative 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

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)

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.

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

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

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

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

INJURY TO THE PERIODONTIUM BY

RESTORATIVE PROCEDURES

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

Cavity and Crown

Preparation

Laceration of the

gingival margin

Inflammatory gingival margins

Injury in the region of

inadequate attached gingiva

GINGIVAL

RECESSION

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

Improper placement of matrix band and wedge

result in poor contour

Food lodgment and plaque accumulation

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.

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,

• Electrosurgical retraction recession & loss

of attachment

• Not indicated in regions of inflammation or of

extremely thin gingival tissue

misuse can cause extensive damage

Gingival recession and sequestration of

bone after electrosurgery

Electrosurgical burn on the palatal aspect of

the maxillary left canine

Retained elastic impression materials, within periodontal

tissues after removing impression can lead to massive

loss of attachments

Provisional RestorationsIf made in haste or without consideration - permanent

damage to periodontium

Critical areas include

The marginal fit

The contour

The surface finish

Overextended Temporary Crowns

• Gingival alterations in interdental, facial and lingual marginal region

• Hyperplasia or recession if attachment is injured severely

UnderextendedTemporary 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

ENDODONTIC PROCEDURES

Root perforations

Frequency - 3 to 10%

Artificial communication b/w root canal system and

supporting periodontium

Root perforations occur during

Access cavity preparation

Root canal preparation

Post space preparation

Location

Cervical

Midroot

Apical

Prognosis

₯Location of perforation- most imp

₯Time lapse b/w occurrence & treatment

₯Size of the perforation

Crestal root perforations - most susceptible to epithelial

migrations & rapid pocket formation

Perforations in furcation areas - because of

proximity to epithelial attachment-

secondary periodontal involvement

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

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

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

PROSTHODONTIC PROCEDURES

Prosthesis are susceptible for plaque formation

inflammatory tissue reactions of mucosa covering

alveolar ridge can occur in response to bridge pontics

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.

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

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

RIDGE-LAP

-Least desirable periodontally

- Difficult plaque control

MODIFIED RIDGE- LAP

-More open lingual form

- Better access for hygiene

OVATE

-Ideal pontic design

- Easy to clean

- Esthetically satisfactory

Pontic design

SANITARY

-Easiest access for

hygeine procedure

-Unesthetic form

Excessive contact of

pontic with ridge Causes initial

blanchingBone resorption

Scraping of edentulous cast for positive contact

Atrophy of underlying bone

Periodontal involvement of abutment teeth

Severely tilted abutments

Deep psuedopocket

on mesial aspect of such

teeth

periodontal breakdown

Removable Partial DentureRPD 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

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

Gingival responses to various types of removable partial dentures

(Bissad et al, 1974 )

Plaque formation and oral hygiene

Increase plaque accumulation on tooth surface in direct

contact with dentures & teeth in opposing arch.

the microbial composition of dental plaque

developing on fifteen abutment teeth

removable partial dentures favored a

proliferation of spiral organisms.

(El ghamrawy , 1976)

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

McHenry et al 1992 The Journal of Prosthetic Dentistry Vol 68, Issue 5, Pages 799–803

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

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

Compared abutment teeth of patients with RPDs, FPDs and

no prosthesis

RPD wearers - greatest plaque and calculus deposition,

probing depth & alveolar bone loss

Rissin et al. (1985) The Journal of Prosthetic Dentistry

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

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

Acrylic Partial Denture

Acrylic non-rigid material whose strength is improved

by ↑ the thickness

Bulky dentures more potential to damage soft tissues

Cause periodontal damage by

Physical stripping of gingiva

Damaging lateral forces

Increased plaque accumulation

Orthodontic Therapy

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.

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

INTERFERENCE WITH PLAQUE CONTROL

Plaque - inflammation –gingivitis

Appliance per se causes plaque accumulation

Inability of the pt to adequately clean

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

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

Microbiology &Orthodontic Band

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.

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

• Adolescents -fixed therapy cause Loss of attachment of 1- 2mm

Alstad & Zachrisson 1979

• Higher prevalence of root resorption Trossello &

Gianelly 1979

• Failed to show any significant changes in adultPolson et al.

1988

Orthodontic Elastics &

SeparatorsInjudicious 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

Band Placement

Stripping of junctionalepithelium. 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 pdlattachment of adj teeth

Occlusal Consideration

Orthodontic movement - Unavoidable occlusal

traumatism - Affect health of periodontium

Disturbance of occlusion produces, although

temporarily- Jiggling type of forces

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

The etiology of root resorption still remains unclear and

is complex, including genetic predisposition and

environmental factors Abass and Hartsfield, 2007

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

Movements of roots outside the confines of alveolar process

- development of mucogingival problems esp in areas of thin

bone & gingiva

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

EXODONTIC PROCEDURES

Injudicious tooth removal initiate periodontal

disease or aggravate existing pathosis in the vicinity

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

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

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

Impacted 3rd Molar extraction

Creation of vertical defects distal to 2nd molar

Kugelberg et al. (1985)-

Retrospective study -215 patients 2yr after surgery

43.3%- probing depth > 7mm

32.1%- probing depth > 4mm

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

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.

PERIODONTAL PROCEDURES

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

• Trauma to the marginal gingivaPolishing

Brush

• Generated heat may cause thermal damage leading to pulpitis

Polishing cup

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

Case reportsBurns due to elect cautery unit

Burn injury caused by heated ultrasonic scaler

Treatment of food impaction with a cold cure acrylic appliance resulting

in chemical burn and pathologic changes in periodontium

Severe ulceration of cheek mucosa due to irritation of molar tube.

The traumatic injury of the acrylic plate of

the pendulum applianceAccidental contact of cheek and alveolar

mucosa with formocresol

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

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

Flaring of anterior teeth due to usage of anterior for chewing

Sinus Expansion Destroying Bone -MissingUpper Teeth

the sinus expand and destroy bone from the “inside out.”

Headaches from Missing Teeth

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

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

Sequale of non replacement of first molar

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.