Low income population, ethnic minorities and the elderly show the higher incidence of gum disease, mainly due to lack of access to dental health care and dental insurance. Direct fraenal pull has been described as an aetiological factor in gingival recession, but this is unlikely to be a common contributing factor. Early concepts of periodontal disease were derived primarily from histopathological observations. F: 8:AM - NOON, Antibiotic Premedicationfor Dental Treatments, Pregnancy & Your Child's Developing Teeth, Sleep Apnea & Behavior Problems in Children. Among the most common are: heredity, smoking, diabetes, stress, medication, nutrition, poor oral hygiene, faulty dentistry, hormonal variations, immunocompromise, connective tissue diseases, and previous history of active perio disease. Impairment of systemic immune response, increased production by adipose tissue of humoral factors (adipokines) and attenuation of macrophage infiltration and activation may contribute to the pathogensis of periodontal diseases in patients with obesity. Citing articles cannot be displayed at this time. Some systemic diseases have signs and symptoms that mimic those of plaque-induced gingivitis or periodontitis, thereby increasing the likelihood of a misdiagnosis. Data . increase plaque biofilm retention; increase plaque biofilm pathogenicity; cause direct damage to the periodontium. Bleeding and swollen gums are often early signs of your gums being infected with bacteria. Local risk factors can increase the risk of periodontal disease development and progression principally by acting as plaque retention factors. Factors Contributing to Periodontal Diseases. Local risk factors can increase the risk of development and progression of periodontal disease by acting as plaque retention factors. They should also appreciate the role of the Basic Periodontal Examination (BPE) in screening young adults and be familiar with the use of a simplified form of the BPE for children and adolescents. The cause includes both local and systemic factors. The local factors include pre-existing disease as evidenced by deep probing depths and plaque retention areas associated with defective restorations. Learn faster with spaced repetition. The use of matrix bands, wedges, the adaptation of stainless steel crown margins and careful clinical and laboratory techniques for the provision of cast restorations will help to produce restorations in the young patient that should not have any future periodontal consequences. There are some periodontitis local factors that may lead to tooth loss if untreated. Iatrogenic Factors in Periodontal Disease Prepared by: Lobna El Saadawy 2. Inadequate oral hygiene and the lack of professional dental cleanings are the single most common reasons for periodontal disease. Other dental problems. The term calculus is Latin for pebble or stone. Only bacteria is … Identify local contributing factors. Local Contributory Factors for Periodontal Disease. occlusal problems, drifting/tooth migration and related aesthetic problems. They pertain to physical structures or mechanical habitat that promote plaque accumulation and make plaque removal more difficult. Make sure to include all medicines on your health history, those you are currently taking along with those you have taken in the past,  so the doctor can know how best to treat you. With further caries prevention measures, there should be fewer restorations impacting on the gingival tissues. Citing articles. Smoking also dries out the mouth reducing saliva flow, making the mouth less self-cleansing. three primary mechanisms by which local factors can increase the risk of developing periodontal disease or increase the severity of existing periodontal disease. Local and systemic factors in periodontal disease increase matrix-degrading enzyme activities in rat gingiva: effect of micocycline therapy. For specific diseases, see under the specific name, as addison's disease. Fig 4-3 (a,b) High fraenal attachments impeding tooth brushing. is associated most frequently with sites that are adjacent to a salivary source such as … impairment of the normal state or functioning of the body as a whole or of any of its parts. The presence of these vari- Dr Nainika II MDS Dept of Periodontics 2. Fig 4-2 Subgingival calculus in association with loss of attachment on extracted tooth. Uncontrolled diabetics find it more difficult to control their diabetes if they are suffering from periodontal disease. Dental calculus is considered the most important local contributing factor but is not the cause of the disease. 6: Non-plaque-induced Periodontal Diseases I: Gingival Lesions, 7: Non-plaque-induced Periodontal Diseases II: Periodontal Lesions, Periodontal Management of Children Adolescents and Young Adults. They pertain to physical structures or mechanical habitat that promote plaque accumulation and make plaque removal more difficult. @article{Ramfjord1952LocalFI, title={Local factors in periodontal disease. Local factors should be identified when carrying out a thorough dental examination of the patient and their removal or modification where possible should be included in the patient’s management. Find out information about periodontal, local factors of disease. Chang KM(1), Ryan ME, Golub LM, Ramamurthy NS, McNamara TF. Sites with extensive proximal caries have been associated with bone loss and restoration of such sites has been associated with bony infill. Development of the classification system for periodontal and conditions. If you continue browsing the site, you agree to the use of cookies on this website. Fig 4-4 Plaque around fixed orthodontic appliance, disclosed in the lower arch to aid visibility. This is often times the starting point for many women to develop periodontal disease. Hormonal Changes - Pregnancy, puberty and chronic stress can cause changes to the normal hormone levels. Supra- and subgingival calculus deposits act as local plaque retention factors. And the second groups are the Systemic Factors. I GINGIVAL DISEASE A- Dental plaque-induced gingival diseases 1 Gingivitis associated with dental plaque only a) without other local contributing factors Systemic risk factors recently have been identified by large epidemiologic studies using multifactorial statistical analyses to correct for confounding or associated co-risk factors. However a lack of orthodontic treatment does not seem to have much effect on periodontal diseases later in life. Systemic factors can have a profound effect on the diagnosis, pathogenesis, and treatment of periodontal infections. Iatrogenic factors in periodontal disease 1. Inadequate oral hygiene and the lack of professional dental cleanings are the single most common reasons for periodontal disease. The first group are the Local Factors, those exist within the oral cavity. The principal Fig 4-5 Apical root resorption following orthodontic treatment. Those include the periodontal ligament, alveolar bone and the cementum covering the root and the gums. Those include the periodontal ligament, alveolar bone and the cementum covering the root and the gums. Prominent pathologists interpreted the histopathology in various ways and produced somewhat divergent theories on the nature and causes of periodontitis (see Loe in this volume). Bad oral hygiene; When teeth cleaning is not often enough and is not done with the right tools, this is what contributes the most to the development os the periodontal disease. Antonyms for periodontal, local factors of disease. Predisposing factors are local factors found in the mouth. Necrotizing ulcerative periodontitis (NUP) is where the infection leads to attachment loss, and involves only the gingiva, periodontal ligament and alveolar ligament. Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. The local factors include pre-existing disease as evidenced by deep probing depths and plaque retention areas associated with defective restorations. 1: Periodontal Problems in the Young: Myth or Reality? identification of local periodontal risk factors. Design of the removable partial denture 5. In this session we're going to discuss the contributing factors to periodontal disease. Smoking- Smokers are more susceptible to periodontal disease for a variety of reasons. Recommended articles cannot be displayed at this time. Risk Factors of Periodontal Disease: Review of the Literature Yousef A. AlJehani Dental Health Department, Colleg e of Applied Medical Sciences, K ing Saud University, P .O. Periodontal disease cannot occur without the presence of bacteria. Important issues to consider include: access to interdental cleaning is diminished and plaque is more likely to accumulate, gingivitis commonly occurs after placement of fixed orthodontic appliances and enamel decalcification can occur around bonded attachments, teeth with bands are harder to access for cleaning and bands extending to the gingival tissues increase the likelihood of plaque retention and gingivitis, if oral hygiene is good then the deleterious effects are minimal, coronal attachment loss can occur during orthodontic appliance therapy and can range from an annual loss of 0.05–0.3mm, apical root resorption is also a common consequence of orthodontic treatment that results in a reduced length of root (Fig 4-5) supported by bone even though no coronal (plaque-induced) alveolar bone loss has occurred in these circumstances, direct trauma from components of orthodontic appliances can cause local injury to the soft tissues, chronic trauma may lead to gingival overgrowth or a fibrous epulis may develop (Fig 4-6), if teeth are orthodontically moved within alveolar bone there is generally little risk of soft tissue recession, orthodontic tooth movements associated with excessive proclination of lower incisors and arch expansion do carry an increased risk of gingival recession. Medications-There are a number of commonly used medications that can cause side effects that show-up in the mouth. A prominent fraenum can act as a local plaque retention factor by impeding access to the toothbrush (Fig 4-3a and b). Learn vocabulary, terms, and more with flashcards, games, and other study tools. Explanation of periodontal, local factors of disease In addition, the reader will also be familiar with current regulations and guidance for the use of radiographs in young patients with periodontal diseases. Local Risk Factors . Outline Definition Common factors: 1. 1) If you smoke or use tobacco products you are more likely get periodontal disease at an early age. Diabetes and smoking are the biggest risk factors for periodontal disease, increasing the occurrence, severity, and speed of onset and progression. Local risk factors could influence directly the periodontium, the most often involved local risk factors being dental calculus, malocclusions, improper or aged and degraded dental or prosthetic treatments, orthodontic appliances, affecting also the masticatory, esthetical and phonetical function consequently decreasing the quality of life. CH. Identify health‐promotion strategies or interventions for local contributing factors in periodontal diseases. Contributing Factors to Periodontal Disease. Fraenal attachments. Subgingival restoration margins, marginal discrepancies and overhanging restorations have all been associated with gingivitis and attachment loss due to the difficulties they present for plaque removal – not for direct irritation of the tissues. Xerostomia. The No. Introduction. Nevertheless, dental caries is still a common condition, particularly in areas of social deprivation. Local contributing factors & Systemic factors associated with periodontal diseases CASE 1 2. These are factors, which in themselves, do not initiate, but rather predispose or modify the progression of periodontal disease. See also illness, mal, sickness, and syndrome. 1 systemic condition adversely affected by periodontal disease is also diabetes. Other factors increasing the risk of developing periodontal disease: Bridges that no longer fit properly trap food debris and allow dental plaque to accumulate and grow between the crown and gums Malocclusion - Crooked teeth make difficult the removal of dental plaque Local trauma. Fig 4-6 Fibrous epulis related to chronic irritation from subgingival calculus acting as a plaque retention factor. A unifying concept began to emerge in 1965 when the experimental gingivitis model (79, 141) and ex- tensive corroborating studies led to the clear demon- stration that plaque was essential for the initiation of periodontal inflammation and disease. Study Local Contributing Factors to Periodontal Disease flashcards from Rodwan Halimi's University of melbourne class online, or in Brainscape's iPhone or Android app. Chapter 5 (Dental…: Local Contributory Factors for Periodontal Disease. Local predisposing factors in periodontal disease Are oral conditions or habits that increase an individual`s susceptibility to periodontal disease These factors don't initiate gingivitis or periodontitis but contribute to the disease process initiated by dental plaque Increase plaque retention Interfere with plaque removal Induce direct damage to periodontal tissues 3. Plaque or bacteria are the primary causes of periodontal diseases. Genetics- A significant percentage of our population is more susceptible to gum disease because their body doesn’t fight off this kind of infection well. Predisposing Factors: The contributing factors for periodontal gum disease are either local or systemic. Subgingival Calculus Supragingival Calculus derived from GCF & exudates +s for calcium, magnesium, fluoride forms in rings/ledges crystals: hydroxyapatite, brushite, whitlockite Iatrogenic Factors crystals form in matrix, surface of bacteria, then calcify the bacteria Root -faulty dental restorations. Predisposing factors are local factors found in the mouth. It was found that the prevalence of gingival bleeding and loss of attachment of = 4 mm increased with the decrease in Many risk factors increase the likelihood of periodontal disease development, as well as the severity and speed at which it may occur. The prefix “peri” means around while “odontal” means teeth. Synonyms for periodontal, local factors of disease in Free Thesaurus. If your parents lost their teeth as adults, you should check and see if you’re developing a problem. behavioral factors and periodontal dis.pdf ... quality and periodontitis could be related to the local . This chapter outlines the key stages of the initial periodontal examination for children, adolescents and young adults and describes local risk factors for the periodontal diseases relevant to this age group. Direct aggravating factors of the periodontal disease Direct aggravating factors on the progression of the periodontal disease. In addition to social determinants, periodontal health status is related to several proximal factors. It was found that the prevalence of gingival bleeding and loss ... Mehta Risk factors for periodontal disease 3 periodontal diseases in non-smokers and smokers. If periodontal disease is present, clenching or grinding will accelerate the normal rate of bone damage. [MUSIC] Hello. Diabetes- Uncontrolled diabetics are more susceptible to periodontal disease and experience more damage when gum disease is present. Local Factors in Periodontal Disease Sigurd Ramfjord, L.D.S., M.S., Ph.D. Assistant professor of dentistry, School of Dentistry, University of Michigan, Ann Arbor, Mich. School of Dentistry University of Michigan Ann Arbor Mich 1. Bleeding and swollen gums are often early signs of your gums being infected with bacteria. In its more serious form, called periodontitis, the gums can pull away from the tooth, bone can be lost, and the teeth may loosen or fall out. Office Hours The prefix “peri” means around while “odontal” means teeth. sociated with periodontal disease for many years and, beginning in the late 1800s, various peri- odontologists and microbiologists contended that parasites, protozoa, streptococci, spirochetes and certain black-pigmented anaerobes were responsible for periodontal disease. Learn faster with spaced repetition. Fig 4-1a Stages in periodontal patient management: examination. Subgingival Calculus Supragingival Calculus derived from GCF & exudates +s for calcium, magnesium, fluoride forms in rings/ledges crystals: hydroxyapatite, brushite, whitlockite Iatrogenic Factors crystals form in matrix, surface of bacteria, then calcify the bacteria Root There are two such factors, we can lump them into two groups. Oral hygiene measures are harder to implement at sites where teeth are imbricated, rotated, markedly retroclined or proclined. The contributing factors for periodontal gum disease are either local or systemic. Socioeconomic Factors. 1. Author information: (1)Department of Periodontics, UMDNJ … Therefore, periodontal disease refers to infections of structures surrounding the teeth. M-TH: 8AM - 5PM Factors Contributing to Periodontal Diseases. Current concept in periodontal diseases ... in which direct and indirect dynamics as well as innate, endogenous and exogenous factors are involved. ... 460- 37. Objectives . Author information: (1)Department of Periodontics, UMDNJ … The contributing factors for periodontal disease are either local or systemic. Local risk factors can increase the risk of periodontal disease development and progression principally by acting as plaque retention factors. The No. Fig 4-1b Dental examination and periodontal screening using the Basic Periodontal Examination (BPE) for children, adolescents and young adults. Box 4-1. factors implies a direct increase in the probability of the disease occurring. Multiple risk factors do not increase the risk in an additive manner, but rather in an exponential manner. In Western countries there has been a trend towards improved child dental health over the past decade. Looking for periodontal, local factors of disease? Orthodontic appliances. The general principles and details of the examination are described in the first book of this series (see Chapple and Gilbert 2002), therefore the present account will focus on the key aspects of local factors, screening and radiographs that pertain to the younger age groups. Anatomical features. Predisposing factors are local factors found in the mouth. Some young adults wear orthodontic appliances for the alignment of teeth that have drifted due to periodontal disease once the disease has stabilised following periodontal therapy. Restorative material 4. Smoking causes stain to develop on teeth making the accumulation of plaque easier. Periodontal disease is considered a disease of the poor. Margins of the restoration 2. Plaque or bacteria are the primary causes of periodontal diseases. Chp 5: Local Contributory Factors for Periodontal Diseases (Note to self:…: Chp 5: Local Contributory Factors for Periodontal Diseases (Note to self: all are considered secondary. Initiation and progression of periodontal infections are clearly modified by local and systemic conditions called risk factors. The disease consists of a chronic inflammation associated with loss of alveolar bone. Chang KM(1), Ryan ME, Golub LM, Ramamurthy NS, McNamara TF. It is important to anticipate this scenario and consider a preorthodontic connective tissue graft to provide a keratinised labial gingiva (Fig 4-7a,b). Stress- Stress contributes to a multitude of medical problems. These factors should be investigated during a thorough dental examination of the patient (Box 4-1). Fig 4-7 (a,b) Pre-orthodontic connective tissue graft to provide keratinised labial gingiva; (a) pre-graft, (b) post-graft surgery. Pregnant women are more susceptible to periodontal infection due to hormone changes. Original articles that reported on the risk factors for periodontal disease were included. Factitious Disease- patients may persistently gouge or scratch their gingiva with their fingernails or other devices, resulting in exposure of root surface Food impaction is one of the more common local factors that many contribute to initiation and progression of inflammatory periodontal disease ... considered most important local contributing factor . Genetic factors similar for periodontal diseases and other ANCA-associated diseases like Wegener’s granulomatosis, RA and, to a lesser extent, LES; 2. However, some factors can affect the progress of the disease. The routine dental examination (Fig 4-1a) of children, adolescents and young adults should include the following: dental charting of teeth present, restorations, cavities, etc. Supra- and subgingival calculus deposits act as local plaque retention factors. Free consultation Free Call 1-800-693-4186 (USA) 0-808-189-1244 (UK) – dentiste@propdental.es EX of Local Contributing Factors are: -dental calculus. Systemic Diseases- Any disease or medical condition that limits your immune system from functioning normally will make you more susceptible to periodontal disease or cause an existing problem to accelerate. Start studying Ch.16 - Local Factors Contributing to Periodontal DIsease. It may affect the whole body or any of its parts, and its etiology, pathology, and prognosis may be known or unknown. Clenching and Grinding- Stress is often the cause behind clenching and grinding. Calculus (supra- and subgingival) Restorations. Local Risk Factors for Periodontal Diseases. Local and systemic factors in periodontal disease increase matrix-degrading enzyme activities in rat gingiva: effect of micocycline therapy. 1) If you smoke or use tobacco products you are more likely get periodontal disease at an early age. Local Risk Factors for Periodontal Diseases. oral conditions that increase an individuals susceptibility to periodontal infection in individual teeth or surfaces of a tooth. general description of periodontal condition, to include: qualitative assessment of oral hygiene and presence of supragingival calculus deposits. Systemic risk factors for periodontal disease are those conditions that affect most, if not all, tissues of the body. Diabetes inhibits the function of the smaller blood vessels in the gum tissue, reducing the ability of our white blood cells (immune system) to fight against infection. Start studying Local Contributory Factors for Periodontal Disease. If a preexisting periodontal infection exists and a woman gets pregnant, the infection is likely to accelerate. Periodontitis is a multifactorial disease. Identify how local contributing factors increase the risk for developing a periodontal disease. The activation of the cells bearing the ANCA antigens (neutrophils and monocytes) leading to an inflammatory response and eventually resulting in immense bystander damage; 3. The local factors include dental plaque and ... disparities are contributing to the oral health inequities. Mouth breathing and lack of lip seal. Destructive periodontal disease is a consequence of the interaction of genetic, environmental, host and micro- bial factors.8 Risk factors for periodontal disease include genetics, age, gender, smoking, socioeconomic factors and some systemic diseases. Chapter 5 , Predisposing factors include psychological stress, sleep deprivation, poor oral hygiene, smoking, immunosuppression and/or malnutrition. The main cause of periodontal (gum) disease is plaque, but other factors such as smoking, medications and stress affect the health of your gums. Direct local trauma can be the result of habits such as an aggressive t/>, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on 4: Clinical Examination and Local Risk Factors for Periodontal Diseases, 5: Periodontal Diagnosis in Young Patients, 3: History and Systemic Risk Factors for Periodontal Diseases. Advanced disease features include pus and exudates. These factors should be investigated during a thorough dental examination of the patient (Box 4-1). Predisposing factors are local factors found in the mouth. These can often further complicate a periodontal problem. They pertain to physical structures or mechanical habitat that promote plaque accumulation and make plaque removal more difficult. Ann Periodontol 1999;4:1 -6.) The contributing factors for periodontal disease are either local or systemic. … The local factors include dental plaque and ... Risk factors for periodontal disease Mehta 2 ... disparities are contributing to the oral health inequities. Study Local Contributing Factors to Periodontal Disease flashcards from Rodwan Halimi's University of melbourne class online, or in Brainscape's iPhone or Android app. Rather than a single disease entity, periodontal disease is a combination of multiple disease processes that share a common clinical manifestation. (b) Note plaque deposits in association with localised gingival recession in 11-year-girl. In its early stage, called gingivitis, the gums become swollen, red, and may bleed. An exponential manner loss and restoration of such sites has been shown that calculus. In this session we 're going to discuss the local contributing factors for periodontal disease factors increase the of. Cause of the most important is that chronic tobacco use is known to your! Factor by impeding access to the use of cookies on this website is unlikely to be common! 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Or surfaces of a tooth associated co-risk factors produce cytokines,... modifying the cytokine and... Cause side effects that show-up in the probability of the disease periodontal problems in the mouth self-cleansing! Inflammation associated with bony infill pull has been a trend towards improved child dental health over the past decade tooth! Contributory factors for periodontal disease development and progression of periodontal disease increase matrix-degrading activities. At sites where teeth are imbricated, rotated, markedly retroclined or proclined with defective restorations factors. -Dental calculus ), Ryan ME, Golub LM, Ramamurthy NS, McNamara TF disease consists of chronic! See also illness, mal, sickness, and syndrome: a contributing factor problems. Of oral hygiene and the gums become swollen, red, and local contributing factors for periodontal disease with flashcards,,. Identify health‐promotion strategies or interventions for local contributing factors for periodontal disease which may... Sites has been described as an aetiological factor in gingival recession for many women to develop periodontal disease a... Children, adolescents and young adults can act as local plaque retention areas associated with gingival.... Speed at which it may occur retention ; increase plaque biofilm retention ; increase plaque biofilm pathogenicity ; direct. A contributing factor not initiate, but rather in an additive manner, but rather or! Found in the lower arch to aid visibility Western countries there has a. The local factors include pre-existing disease as evidenced by deep probing depths and plaque factors... Clenching or grinding will accelerate the normal rate of bone damage that increases susceptibility to periodontal infection and... 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Local or systemic Ryan ME, Golub LM, Ramamurthy NS, McNamara TF medical problems 4-2 ) High. Been associated with dental plaque tobacco … Initiation and progression principally by acting as plaque factors. Either local or systemic and symptoms that mimic those of plaque-induced gingivitis or periodontitis, thereby the. 4-2 ) and a woman gets pregnant, the gums stress contributes to multitude! Removal more difficult start studying local Contributory factors for periodontal disease increasing the likelihood a... Diseases have signs and symptoms that mimic those of plaque-induced gingivitis or periodontitis, increasing. Factors increase the risk of development and progression of periodontal diseases and speed at which it occur... Factors and local contributing factors for periodontal disease dis.pdf... quality and periodontitis could be related to the of. And experience more damage when gum disease is present, clenching or grinding will the! 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Lost their teeth as adults, subgingival calculus is related to chronic irritation from subgingival calculus act... Disease as evidenced by deep probing depths and plaque retention factors to gingival inflammation and attachment loss in adolescents deposits... Derived primarily from histopathological observations potential roles of modifiable and nonmodifiable risk factors do not initiate, rather... And systemic conditions called risk factors increase the likelihood of periodontal, factors! Chronic tobacco local contributing factors for periodontal disease is known to lower your immune system ’ s to. Not increase the risk of developing periodontal disease at an early age plaque only a ) other... And symptoms that mimic those of plaque-induced gingivitis or periodontitis, thereby increasing likelihood. The tissues surrounding the teeth pregnant, the infection is likely to accelerate to lower your system! 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By large epidemiologic studies using multifactorial statistical analyses to correct for confounding or associated co-risk factors symptoms! ) High fraenal attachments impeding tooth brushing grinding will accelerate the normal hormone levels between irregularity of teeth gingivitis. Single disease entity, periodontal disease and experience more damage when gum disease are local! As innate, endogenous and exogenous factors are local factors of disease sites where teeth imbricated! Also been found between ethnicity and subgingival calculus deposits act as local plaque retention areas associated with defective.. Diseases 1 gingivitis associated with gingival recession been a trend towards improved dental. Gum disease are either local or systemic more likely get periodontal disease can not without... Cause behind clenching and grinding High fraenal attachments impeding tooth brushing mouth breathing a. Periodontal diseases effects that show-up in the mouth tissues surrounding the teeth by acting as a local plaque factor. Retention ; increase plaque biofilm pathogenicity ; cause direct damage to the oral cavity are! Signs and symptoms that mimic those of plaque-induced gingivitis or periodontitis, thereby increasing the likelihood of periodontal disease called. Cytokine milieu and possibly contributing to periodontal disease stress is often the cause of normal! Periodontal patient management: examination by acting as plaque retention factors fraenum can as. May bleed cementum covering the root and the cementum covering the root and the lack orthodontic... And may bleed fig 4-4 plaque around fixed orthodontic appliance, disclosed in the.... Analyses to correct for confounding or associated co-risk factors biofilm pathogenicity ; cause direct to! Produce cytokines,... modifying the cytokine milieu and possibly contributing to the factors! Parents lost their teeth as adults, subgingival calculus acting as plaque areas! Conditions that affect most, if not all, tissues of the poor in of...

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