Diseño de Sprints

W hen complex periodontal treatment is contemplated, the feasibility o f m aintaining a state o f health depend upon the patient’s ability to carry out effective cleaning prior to treatment (Kieser, 1986). There is strong scientific evidence that plaque control is the essential factor in the prevention and treatment o f periodontal disease (Pilot, 1980; Preber and Bergstrom, 1990). Early studies on the susceptibility o f the alveolar bone to surgical trauma showed that plaque re-infection would seriously affect the benefit o f any surgical method (Bergstrom and Henrikson, 1974; Rosling et al 1976). Pilot (1980) concluded, in the analysis o f effectiveness o f periodontal treatments, that all studies indicating success have reported meticulous oral hygiene. Type o f periodontal surgery does not appear to be o f prime importance. Pilot’s evaluation suggested that periodontal surgery should never be carried out before patients have demonstrated willingness and be capable of maintaining a clean dentition.

It is generally accepted that supragingival plaque can be eliminated, reduced or modified by means o f simple mechanical or chemical measures. M echanical plaque control, including cleansing o f the dentition with

toothbrush, floss, and toothpicks, has been shown to be effective in maintaining periodontal health, in controlling gingivitis and preventing the development of periodontitis (Loe, 1993). Since gingivitis seems to be a non­ specific inflammatory process with which over 70 different species o f bacteria have been associated (Moore, 1982), periodontal disease prevention must still be based on non-specific control o f bacterial plaque deposits (Burt, 1988; Sheiham, 1996). Beyond a certain level o f plaque, which is compatible with no progression of gingivitis to severe periodontal disease, the more plaque the more severe the periodontal disease (Sheiham, 1991). Burt (1988) explored the level o f non-specific plaque compatible with oral health by analysing data from the NHANES I national survey (Burt et al, 1985). The results showed that oral hygiene levels of people at all ages who had 25 or more teeth present were remarkably similar and suggested that an oral hygiene level that corresponds to OHI-S scores o f 0.3-0.6 might be compatible with tooth retention throughout life. Claffey et al (1990) demonstrated that when plaque was present at more than 75% o f 8 examinations during a 2-year period following surgical therapy, the predictability for probing attachment loss was 15%. Newman et al (1994) showed in their evaluation for predictive treatment model that the patient’s post-treatment plaque control level was strongly associated with treatment success. 75% o f patient with good plaque control, defined as less than 10% o f their teeth surfaces with plaque, had successful outcomes. While only 55.6% o f the patients with moderate or worse plaque control were associated with treatment success.

8.3.2 Smoking

There is abundant evidence o f association between smoking and periodontal disease (Pindborg, 1947; Amo et al, 1958; Solomom et al, 1968; Sheiham,

1971; Lasvstedt, 1975). More recent studies have shown that smokers have more calculus, staining, deeper pockets and more bone loss, but less clinical inflammation than the non-smokers (Rivera-Hidalgo, 1986; Komman and Loe, 1993; Schenkein et al, 1995). Even in subjects with good oral hygiene, smokers had significantly more bone loss than non-smokers (Bergstrom and Eliasson, 1987; Bergstrom et al, 1991). Bergstrom et al (1991) demonstrated an average periodontal bone reduction o f 0.7 mm in smokers and 0.4 mm in non-smokers. These studies suggest that smoking may have a substantial modifying effect on the process o f connective tissue destmction once it has been initiated (Komman and Loe, 1993). However, plaque level in smokers has been inconsistently reported as less (Feldman et al, 1983), the same (Alexander, 1970; Bastian and Waite, 1978; Bergstrom, 1989) or more (Preber et al, 1980; Modeer et al, 1980; MacGreger and Rugg-Gunn, 1984). Smoking was found to be related to less favourable tooth bmshing performance (M acGregor and Rugg-Gunn, 1984; Sakki et al, 1995). In a study o f periodontal pathogens, Preber et al (1992) showed that smokers and non- smokers do not differ in the relative frequency, or different combinations of periodontal pathogens. This suggests that smoking mainly exerts a systemic influence rather than primarily adding to local destmctive factors. However, it is likely that the combined effect from smoking and plaque infection is more destmctive than either factor alone (Bergstrom et al, 1991).

Smoking has been associated with a decreased healing rate o f duodenal ulcers (Lam and Koo, 1983), rhytidectomies (Riefkohl et al, 1986) and surgical removal o f impacted teeth (Sweet and Butler, 1979). In periodontal treatment, studies have demonstrated that the outcome of various therapeutic modalities is significantly compromised in smokers compared with non-smokers (Preber

and Bergstrom, 1990; Jones, 1992; Ah et al, 1994). Preber and Bergstrom (1990) found less probing depth reduction in smokers after 12 months follow- up o f surgical therapy. The difference was strongly significant even accounting for plaque. MacFarlane et al (1992) indicated the higher prevalence o f smoking in patients at high risk o f recurrent refractory periodontitis. In the 4 weeks to 6 years follow up for patients o f 6 periodontal treatment methods. Ah et al (1994) showed that smokers exhibited less gain o f attachment level in every follow up periods.

Mendel (1994) concluded from epidemiological and case-control studies, that smoking is an important risk factor for attachment loss and loss o f supporting alveolar bone in adult periodontitis. In the evaluation o f a representative sample o f the United States population as part o f the National Health and Nutrition Examination Surveys, Ismail et al (1983) evaluated the relationship o f smoking to periodontal disease in 3000 individuals. The results suggest^ that current smoking has an independent direct association with periodontal disease, although less strong than the association of oral hygiene and age with periodontal disease. However, after controlling for oral hygiene, age, and the other confounding factors, the past smoker had higher but not significantly different Periodontal Index scores than the non-smokers. There were no significant differences in the current smokers with different types o f tobacco (cigarettes, cigars and pipe), duration of smoking (15 or fewer years and more than 15 years) or number o f cigarettes smoked per day (one package or less and more than one package). Bergstrom et al (1991) found in 24-60 year old Swedes that subjects smoking more than 10 cigarettes per day exhibited more bone loss than those smoking less. Three recent studies o f risk factors for periodontal disease in elderly populations in Iowa (Levy et al, 1987), North

Carolina (Beck et al, 1990) and Ontario (Locker and Leake, 1992) showed that smoking was the only one factor which survived multivariate analysis. Locker and Leake (1993) found that the odds ratio of having a history o f smoking and currently smoking groups were 2.3 and 2.7 respectively for predicting the sites with periodontal attachment loss o f 2 mm or more.

8.4 Association between periodontal pockets and behaviour-related