الفهرس 
Introduction and Aim of the WorkOnly 14 pages are availabe for public view
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Abstract
Periodontal disease is a major oral health problem both in developed and developing countries. chronic Periodontitis is the most prevalent form. It can begin in adolescence but the disease usually does not become clinically significant until people reach their mid-30s. Plaque and calculus deposits in relation to teeth are the main cause of chronic periodontitis.
Susceptibility to periodontitis varies greatly between individuals who harbor the same microflora, the bulk of evidence points to the host’s inflammatory response to bacterial challenge as a major determinant of susceptibility.
Systemic diseases, local factors and environmental factors are risk factors that strongly influence the severity of the disease and the response to treatment.
Risk factors may be modifiable or non-modifiable. Modifiable risk factors are usually environmental or behavioral in nature such as (Smoking, Diabetes mellitus, Oral Hygiene, Stress Obesity, while non-modifiable risk factors are usually intrinsic to the individual and therefore not easily changed such as Age and Genetics. Identification of susceptible individuals prior to developing periodontitis and identifying risk factors that might be modified is a must in order to prevent or alter the course of periodontal disease.
Early and prompt periodontal therapy is a must to preserve the natural dentition, improve comfort, esthetic and function. Nonsurgical periodontal therapy is the corner stone of periodontal therapy and the first recommended approach to the control of periodontal infections.
The objective of the present study was: to identify risk factors of periodontitis through Meta analysis. To implement nonsurgical periodontal therapy, and assess the response of patients to this modality of treatment. Moreover to determine the time needed to improvement / relapse after non surgical periodontal treatment among patients with different risk factors.
The study was carried out on 2 phases: the first was the Meta analysis of all published observational studies conducted on individuals aged 18 and older. 51 studies representing 46,455,486 participants were included in this meta-analysis. All studies were published from 1998 to 2017. The reported patient’s age ranged from31 to 90 years .All the studies showed that obesity, diabetes, smoking, stress, gender, age, level of education, socio economic status and marital status were risk factors for periodontitis.
The first phase of the study revealed that: periodontitis among old age (≥45) were 2.15 time that of young age (<45), among males were 1.5 time relative to females. Among married persons 1.37 time risk relative to un married , among persons with low socioeconomic level 1.68 times relative to those with high socioeconomic level among uneducated were 2.13 times relative to educated, among diabetic persons 2.17 times risk relative to non diabetic, among smokers were 1.67 times relative to non smokers, among obese were 1.80 times relative to normal weight persons, among persons under stress 1.11 times risk relative to those with no stress, and cases living sedentary life were 11% times more liable for developing periodontitis than those who were physically active.
The second phase was carried on 100 cases with chronic periodontitis who attended Alexandria dental research center (ADRC) in the period from March to August 2016. All participants undergone a hygiene phase that involved full mouth scaling and root planing by using ultrasonic scalars and hand instruments and this completed in one session. Polishing was also done. Patients were instructed for proper oral hygiene daily and amoxicillin 500 mg and metronidazole 250 mg were prescribed 3 times a day for 10 days. Follow up was done once per month for a period of 6 months during which supra-gingival plaque was removed and oral hygiene instructions were reinforced.
The second phase of the study showed that, all participants completed the 6-month follow up, none of the patients revealed any major periodontal inflammatory symptoms, or allergic reactions during the entire study period. 52% of the patients were males and 48% were females, with mean age of 42.92 ± 6.96 years , ranging from 27 to 65 years, 67%were (≤40 years) and 33% were (>40 year), 81% of the patients were Married. 30% were diabetic, out of them 53.3 % were controlled. (38%) patients were obese, 35% were smokers and (60%) out of them were heavy smokers (≥20 cigarettes daily).
The average number of teeth examined per subject was 22.8±2.95, and 688 teeth with pockets depth of ≥4mm were examined (average 6.88±2.54 teeth per subject), twenty eight percent (28.1%) of them had a pocket probing depth of 4–6mm and 71.9% of them had pocket depth of 7mm or greater. 15.4% of the examined teeth with pockets were anterior (incisors and canines), 84.6% were posterior (molars and premolars). Nearly two third of all the examined teeth were in the lower arch. No teeth under investigation had to be extracted.
Assessment for periodontal pocket depth (PPD) and clinical attachment level (CAL) were performed on six site per tooth and the periodontal pockets and the clinical attachment loss were concentrated in the inter proximal sites where 98% of moderate pockets and CAL of (4-6mm) were located in disto-buccal sites while 27% of severe pockets and CAL of ≥7mm were in mesio- buccal sites.
The second phase of the study revealed that: Pocket improvement after nonsurgical periodontal treatment among young age patients (≤ 40) recorded 2.5folds relative to old age patients (> 40). Non smokers and light smokers recorded double folded relative to heavy smokers. Both non diabetics and controlled diabetics recorded 1.16 and 1.07 respectively times relative to non controlled patients. Patients with 4-6 mm pocket depth are 1.51 time relative to those with ≥7 mm pocket depth. Periodontal pockets in posterior teeth are .60 times less to improve relative to those in anterior teeth.
The second phase of the study also revealed that: Pocket relapse after nonsurgical periodontal treatment among controlled diabetics were 0.681 folds less relative to non diabetic patients, among un controlled diabetics were 2.32 folds more relative to non-diabetics. Light smokers recorded 1.96 times more relative to non-smokers. Heavy smokers were 2.88 folds more relative to non smokers. Periodontal pockets in anterior teeth recorded 1.07 times more relative to pockets in posterior teeth. Sever Pockets (≥7 mm depth) recorded 1.34 time more relative to moderate pockets (4-6 mm depth).
Among the all included factors only age and smoking status were found to be the most statistically significant predictors for PPD improvement, while no any statistically significant predictor for relapse after adjustment of all other explanatory variables in the models.
Significant improvement was detected as proved by the clinical parameters (PPD, Plaque, calculus and % of BOP sites).
Conclusions
1- Periodontal disease affects large number of individuals around the world and is of major oral health problem both in developed and developing countries.
2- Periodontitis is a multifactorial disorder. Microbial dental plaque biofilms are the most principal etiological factor.
3- The first clinical manifestation of periodontal disease is the appearance of periodontal pockets, recession, or both and eventually tooth loss.
4- Individuals are not equally susceptible to periodontal disease and some risk factors work to change the susceptibility or resistance of individuals to the disease, which can be systemic or local.
5- Un educated, old age, depressed, male of low socio economic level, low physical activity, smokers, diabetic and obese are more susceptible to periodontal disease.
6- Patients with periodontitis with severe gingival inflammation who do not respond to routine peri¬odontal therapy should be screened for diabetes.
7- Non-surgical periodontal therapy (NSPT) in conjunction with Systemic use of metronidazole and amoxicillin resulted in a significantly better clinical periodontal outcome among non-risky subjects (young age females, married, non smokers, on obese, with moderate pockets of anterior teeth.
8- Relapse is likely to occur after improvement among cases with risk factors for periodontitis (old age, male, smokers, obese, uncontrolled diabetic, with sever pockets of posterior teeth.
Recommendation
1- Oral health assessment for early detection of any sign for periodontitis.
2- Special care of oral health should be directed to cases at risk for periodontitis.
3- Full periodontal assessment is required. These includes full mouth probing and bleeding on probing assessments, together with assessment of other relevant parameters such as recession, tooth mobility and furcation involvement.
4- Instead of surgical therapy, non surgical periodontal debridement coupled with systemic use of amoxicillin and metronidazole, and continued maintenance procedure using plaque control program can be applied for management of periodontitis.
5- Promoting a healthy lifestyle, reducing tobacco consumption, motivating oral self‐care behaviors, together with normal weight maintenance, are necessary to reduce periodontal disease.
6- Further long-term studies employing larger study populations are needed to determine the efficacy of the assessed adjunctive antimicrobial therapy on the prevention of disease progression in patients with chronic periodontitis.