Local Contributing Factors

 

6: Local Contributing Factors

Case 6Local Contributing Factors

CASE STORY

As with drug‐induced gingivitis, there are many cases in which local contributing factors play a role in the development of gingival and periodontal diseases. They may be found in most patients that a dental professional would see on a daily basis. Depending upon the patient’s risk assessment and immune response local contributing factors may or may not play a role in the development of the gingival or periodontal disease. Patients may present with restorations that have poor, open, or over hanging margins. The patient may also have crowns, crown and bridge, or removable partials among other dental restorations. Calculus build‐up is also a contributing factor and should be considered. There are many other local factors that play a role in developing or contributing to an already existing gingival or periodontal condition.

PROBLEM‐BASED LEARNING GOALS AND OBJECTIVES

• Identify local contributing factors.
• Identify how local contributing factors increase the risk for developing a periodontal disease.
• Identify health‐promotion strategies or interventions for local contributing factors in periodontal diseases.

Medical History

The patient’s medical history can vary and range from the adolescent to the geriatric populations.

Dental History

The patient’s dental history may include a lack of dental care or below‐standard care resulting in a large formation of calculus deposits or poor broken‐down restorations.

Social History

The patient’s social history would be dependent upon the age and values of the individual.

Assessments

Extraoral/intraoral examination

Dependent upon the individual.

Periodontal Assessment

• Gingival Statement: Consideration for a generalized gingival statement as well as significant attention to localized gingival inflammation. Gingival inflammation can range from mild to severe. It can involve all areas of the gingiva including marginal, attached, and mucogingiva.
• Pocket depths: Vary
• SBI: Vary but would be high around local contributing factor
• PCR: Vary but most likely would be high around local contributing factor
• Calculus classification: Vary but most likely would be heavy if calculus is a local contributing factor

Dental Charting Assessment

• Occlusion: Dependent upon individual but may include: crowding; open contacts; and lingual, buccal, and torsoversions
• Restorations: Vary but consideration for Class II and Class V restorations, crowns and bridges, partials
• Broken teeth: Dependent upon individual
• Missing teeth: Dependent upon individual

Radiographic Findings

• Bone loss will vary: Slight to severe

Risk Assessments

• Vary depending upon the patient’s modifiable and nonmodifiable factors

Problem List

• Gingival inflammation and bleeding
• Probing depths
• Bone loss
• Missing or broken teeth
• Malocclusion that may include: lingual, buccal, and torsoversions; and crowding

Dental Hygiene Diagnosis

Unmet Human Need	Evidenced (caused) by	Signs/Symptoms
Integrity of the skin and mucous membrane	Plaque and calculus accumulation	Bleeding, inflamed gingiva
Biologically sound and functional dentition	Inadequate dental careMalocclusion‐crowding, malpositioned teeth	Ill contoured restorationsBleeding, inflamed gingiva, bone loss, mucogingival involvement

Planned Interventions

Interventions	Goals	Evaluation
Oral Health Education	Patient will understand the disease process and contributing factors associated with the periodontal condition	Patient will schedule appointments for care and follow up with periodontist
Removal of calculus deposits and biofilm accumulation	Patient will understand the disease process and the importance of dental visits	Patient will schedule appointment for treatment and follow up with a periodontist
Dental treatment	Patient will make an appointment with the dentist for consultation on missing teeth (permanent replacements) and broken toothPatient will make an appointment with a periodontistPatient will make an appointment with an orthodontist	After dental hygiene care and periodontal referral

Discussion

The appointment schedule would be dependent upon the level of periodontal involvement and the local contributing factor(s). It could range from a simple prophylaxis to nonsurgical periodontal therapy. Referrals for dental, periodontal, and orthodontia care must also be considered to remove the local contributing factors.

Local contributing factors play a role by increasing the risk for developing a periodontal condition or increase the severity of an existing condition in a variety of ways. One way is they contribute to an increase in plaque/biofilm retention. An example of this would be an over hanging margin on a Class II restoration or a Class IV composite restoration at or below the gingival margin. Another way they contribute is to cause direct damage to the periodontium. An example of this would be a partial denture impinging on the periodontium or trauma from misuse of oral health aids (Nield‐Gehrig and Willmann 2016).

Biologically sound and functioning dentition as an unmet human need may be caused by restorations that are poorly contoured, have open margins, or overhanging margins. Following are more detailed examples of local contributing factors:

• Figure 2.6.1 shows plaque accumulation around a crown margin. Note the inflammation around the gingival margin. The crown could be bulky or have an open margin. After dental hygiene therapy a re‐evaluation appointment to determine the need for further care is recommended.
• Figure 2.6.2 shows calculus accumulation on the root surface of anterior crowns. Note the crowns are fused leading to difficulty in completing oral hygiene self‐care. The distal margin of the lateral incisor may have an open and overhanging margin. These restorations contain many of the contributing factors for plaque retention and difficulty in cleaning.
• Figure 2.6.3 shows gingival inflammation around anterior crown margins. It appears there is minimal plaque accumulation. The margins could be bulky or it could be a tissue reaction to the dental biomaterials used in the fabrication of the crowns.
• Figure 2.6.4 shows a broken tooth/restoration with plaque accumulation. Planned interventions would include dental care to replace the restoration. Pain should also be a consideration when developing a dental hygiene diagnosis and care plan.
• Figure 2.6.5 shows crowding on the mandibular incisors. Crowding is a local contributing factor in different ways. One way is difficulty for the patient to conduct self‐care and plaque removal. Another way is root proximity contributing to difficulty in root debridement procedures.

Figure 2.6.1: Note the plaque accumulation around the crown margin and associated gingival inflammation. Source: Photo courtesy of Rio Salado College.

Figure 2.6.2: Calculus formation around anterior crowns. Note the crowns are fused and the margin on the distal of the lateral incisor are local contributing factors.

Source: Photo courtesy of Rio Salado College.

Figure 2.6.3: Gingival inflammation around anterior crowns, may be a result of a tissue reaction to biomaterials used in the fabrication or bulky crown margins.

Source: Photo courtesy of Rio Salado College.

Figure 2.6.4: A broken tooth with plaque accumulation and gingival inflammation.

Source: Photo courtesy of Rio Salado College.

Figure 2.6.5: Crowding on the mandibular incisors resulting in difficulty in plaque removal and root debridement procedures.

Source: Photo courtesy of Rio Salado College.

Plaque accumulates for many reasons. One reason may be the patient’s ability to effectively perform self‐care. Another may be the specific dental material used such as a large fill composite that is rough and difficult to polish. Margins that are bulky or have overhangs provide a nexus for plaque accumulation. Broken teeth or restorations have rough margins and lead to plaque accumulation. Realistic goals of educating the patient as to the reason further dental treatment are required as well as oral hygiene care around the restoration. The clinician can use both biologically sound and functioning dentition due to the crown margins being bulky or ill‐fitting or skin and mucous membrane integrity due to gingival inflammation. Dental hygienists can perform margination techniques to remove overhangs on Class II restorations and polish restorations that are rough and plaque retentive. Other than these adjunct interventions a referral for dental services to address concerns must be included.

A dental hygiene diagnosis of integrity of skin and mucous membrane is used to plan for dental hygiene care related to inflammation and calculus accumulation. The evidence of plaque or calculus accumulation accompanied by bleeding, reddened, and edematous gingiva allows for a care plan of nonsurgical periodontal therapy. Examples of these are shown in Figures 2.6.4 and 2.6.5.

• Figure 2.6.6 shows calculus accumulation on the lingual of the mandibular incisors with associated edematous papilla and rolled margins. Calculus as a local contributing factor is a plaque retentive factor.
• Figure 2.6.7 shows heavy subgingival calculus leading to plaque retention and difficulty performing oral hygiene self‐care.

Figure 2.6.6: Calculus formation on the lingual of the mandibular incisors note the edematous papilla and rolled margins.

Source: Photo courtesy of Rio Salado College.

Figure 2.6.7: Heavy subgingival calculus preventing daily plaque removal and contributing to plaque retention.

Source: Image courtesy of Rio Salado College.

Although calculus is not the cause of periodontal disease, it plays a significant role in increasing the risk for development or exacerbation of an existing condition. Plaque accumulation is associated with calculus. Mature plaque that covers calculus can increase the pathogenicity. Interventions include patient education regarding the removal of the deposits and disease progression. Oral hygiene instructions to reduce plaque accumulation and address the patient’s self‐care behaviors can also be employed. Nonsurgical periodontal therapy and adjunctive therapies tailored to the individual patient should also be included.

The American Academy of Periodontists added the addition of a category on “Developmental or Acquired Deformities and Conditions” to address localized tooth‐related factors. Tooth anatomic factors, dental restorations/appliances, root fractures, and cervical root resorption are specifically listed. They have been included as important modifiers of the susceptibility to periodontal diseases. Addressing these tooth‐related factors can affect the outcomes of treatment (Armitage 1999).

Recognizing the risk factors and addressing the patient’s unmet human needs are the initial steps in the process of care. Developing a dental hygiene care plan and interventions that include dental referrals is essential to the outcomes of treatment when dealing with local contributing factors.

Take‐Home Hints

1. Consideration of the removal of local contributing factors
2. Education of the patient in the disease progression and self‐care behaviors
3. Relate the dental hygiene care to the dental hygiene diagnosis
4. Include dental referrals to address biologically sound and functioning dentition.