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Samenvatting Parodontologie 1
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Parodontologie1. INTRODUCTIE ............................................................................................................................................... 5
1.1 GEREGLEMENTEERDE – BESCHERMDE BEROEPSTITELS BINNEN DE TANDHEELKUNDE ......................................................... 5
1.2 NIET GEREGLEMENTEERDE- NIET BESCHERMENDE BEROEPSTITELS BINNEN DE TANDHEELKUNDE ......................................... 5
1.3 OPLEIDING IN PARODONTOLOGIE (3J) .................................................................................................................... 5
1.4 HISTORIEK ........................................................................................................................................................ 6
1.4.1 verleden ................................................................................................................................................ 6
1.4.2 vandaag – doelstellingen ...................................................................................................................... 7
1.4.2.1 parodontologie ............................................................................................................................................... 7
1.4.4.2 beroepsverenigingen ...................................................................................................................................... 8
1.4.3 toekomst – doelstellingen ..................................................................................................................... 8
2. BOUW EN FUNCTIE VAN HET PARODONTIUM .............................................................................................. 9
2.1 GINGIVA......................................................................................................................................................... 10
2.1.1 breedte van de aangehechte (vaste) gingiva ...................................................................................... 11
2.2.2 natuurlijke variatie in gekeratiniseerde gingiva (belangrijk bij poetstrauma) ................................... 11
2.2.3 recessie: afname van gingiva breedte ................................................................................................ 11
2.2.4 epitheel/dekweefsel ............................................................................................................................ 12
2.2.4.1 de buitenzijde van het epitheel .................................................................................................................... 13
2.2.4.2 de binnenzijde van het epitheel ................................................................................................................... 13
2.2.4.3 histologisch en klinisch ................................................................................................................................. 14
2.2.4.4 lamina propria .............................................................................................................................................. 16
2.2.4.5 de col van de gingiva .................................................................................................................................... 17
2.2.4.6 de biologische breedte ................................................................................................................................. 17
2.2 DE ALVEOLAIRE MUCOSA ................................................................................................................................... 17
2.3 HET PARODONTAAL LIGAMENT............................................................................................................................ 17
2.3.1 vezels .................................................................................................................................................. 19
2.3.2 cellen ................................................................................................................................................... 19
2.3.2.1 PL fibroblasten .............................................................................................................................................. 19
2.3.3 groeifactoren ...................................................................................................................................... 20
2.4 VASCULARISATIE .............................................................................................................................................. 20
2.4.1 vaatplexus ........................................................................................................................................... 20
2.5 INNERVATIE EN NEUROFYSIOLOGIE....................................................................................................................... 21
2.5.1 N. Trigeminus ...................................................................................................................................... 21
2.6 HET WORTELCEMENT ........................................................................................................................................ 21
2.7 PROCESSUS ALVEOLARIS .................................................................................................................................... 22
2.7.1 lamina dura......................................................................................................................................... 23
2.7.2 afwijkingen van de processus alveolaris ............................................................................................. 23
3. PATHOLOGIE .............................................................................................................................................. 24
3.1 GINGIVITIS ...................................................................................................................................................... 24
3.1.1 klinische gezonde gingiva ................................................................................................................... 24
3.1.2 klinisch ongezonde gingiva ................................................................................................................. 24
3.1.3.1 afweermechanismen .................................................................................................................................... 25
3.1.3.2 ontstoken gingiva: meten is weten ............................................................................................................... 25
3.1.3 prevalentie gingivitis........................................................................................................................... 27
3.1.4 experimentele gingivitis ...................................................................................................................... 27
3.1.4.1 studie van H. Loë et al 1965.......................................................................................................................... 27
3.1.4.2 Page & schroeder 1976: ............................................................................................................................... 27
3.1.4.3 microbiologie van plaqueaccumulatie .......................................................................................................... 29
3.1.5 vormen van gingivitis .......................................................................................................................... 30
3.1.5.1 chronische gingivitis ..................................................................................................................................... 30
3.1.5.2 bloeding na sonderen ................................................................................................................................... 31
3.1.6 gingivitis take home............................................................................................................................ 32
3.2 PARODONTITIS ................................................................................................................................................ 32
3.2.1 histologie bij parodontitis ................................................................................................................... 33
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, 3.2.2 kenmerken van parodontitis ............................................................................................................... 33
3.2.2.1 botafbraak (Rx) ............................................................................................................................................. 33
3.2.3 gingivitis versus parodontitis .............................................................................................................. 34
3.2.3 indeling classificatie ............................................................................................................................ 36
3.2.3.1 NVvP classificatie van parodontitis anno 2018 ............................................................................................. 36
3.2.4 necrotiserende parodontitis (NP) ........................................................................................................ 41
3.3 NIET-PLAQUE GERELATEERDE AANDOENINGEN ....................................................................................................... 43
3.3.1 virus .................................................................................................................................................... 43
3.3.2 auto-immuunziekte............................................................................................................................. 43
3.3.2.1 orgaan specifieke auto-immuunziekten ....................................................................................................... 43
3.3.2.2 gegeneraliseerde auto-immuunziekten ........................................................................................................ 43
3.3.3 verkleuringen ...................................................................................................................................... 44
3.3.3.1 witte verkleuringen ...................................................................................................................................... 44
3.3.3.2 blauw – zwarte verkleuringen ...................................................................................................................... 45
3.3.3.3 bruine verkleuringen .................................................................................................................................... 46
3.3.3.4 rood – purperen verkleuringen .................................................................................................................... 47
3.3.4 bullae en ulceratieve aandoeningen ................................................................................................... 47
3.3.5 tumoren .............................................................................................................................................. 49
3.4 TANDTRAUMA EN HYPERMOBILITEIT .................................................................................................................... 54
3.4.1 meten van de mobiliteit ...................................................................................................................... 54
3.4.2 incidentie van acute traumata aan het parodontium ........................................................................ 55
3.4.3 therapie .............................................................................................................................................. 56
3.4.3.1 therapie bij avulsie ....................................................................................................................................... 57
3.4.4 chronische trauma door occlusie ........................................................................................................ 60
3.4.5 trauma van occlusie op implantaten .................................................................................................. 63
3.4.6 praktische richtlijnen .......................................................................................................................... 63
3.4.7 conclusies ............................................................................................................................................ 64
3.5 GINGIVALE RECESSIES ........................................................................................................................................ 64
3.5.1 Recessie als gevolg van anatomische factoren ................................................................................... 64
3.5.2 recessies geassocieerd met trauma .................................................................................................... 65
3.5.3 recessies geassocieerd met pathologisch botverlies ........................................................................... 65
3.5.4 pathogenese van recessie ................................................................................................................... 65
4. ETIOLOGIE EN PATHOGENESE VAN PLAQUE-GERELATEERDE PARODONTALE AANDOENINGEN ................. 66
4.1 INLEIDING....................................................................................................................................................... 67
4.2 INNERVATIE EN NEUROFYSIOLOGIE....................................................................................................................... 67
4.2.1 speekslklieren produceren speeksel onder invloed van het zenuwstelsel ........................................... 67
4.2.2 eigenschappen en mondgezondheid .................................................................................................. 69
4.2.3 vorming van tandplaque ..................................................................................................................... 70
4.2.4 initiële hechting en energiebron van de subgingivale flora ................................................................ 71
4.2.5 xerostomie .......................................................................................................................................... 72
4.3 SUPRAGINGIVALE PLAQUEGROEI: MATURATIE EN MINERALISATIE ............................................................................... 74
4.3.1 inleiding .............................................................................................................................................. 74
4.3.2 mechanisme van bacteriële adhesie ................................................................................................... 76
4.3.3 kolonisatie van de mondholte............................................................................................................. 77
4.3.4 plaqueaccumulatie vanuit een klinisch oogpunt ................................................................................ 77
4.3.5 invloed van oppervlakte eigenschappen op de initiële adhesie .......................................................... 79
4.3.6 maturatie van plaque ......................................................................................................................... 80
4.3.7 mineralisatie van plaque (tandsteen) ................................................................................................. 81
4.4 MICROBIOLOGIE VAN PARODONTALE INFECTIES ...................................................................................................... 82
4.4.1 microbiologie van de parodontale infecties ........................................................................................ 82
4.4.2 geschiedenis........................................................................................................................................ 83
4.4.3 supra gingivale plaque ........................................................................................................................ 84
4.4.4 subgingivale plaque ............................................................................................................................ 86
4.4.5 microbiologie van parodontale infecties ............................................................................................ 87
4.4.5.1 gingivitis ........................................................................................................................................................ 87
4.4.5.2 van gingiitis naar parodontitis ...................................................................................................................... 88
4.4.5.3 parodontitis .................................................................................................................................................. 89
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, 4.4.5.4 de aard van parodontale infecties ................................................................................................................ 89
4.4.5.5 op zoek naar de etiologie van parodontitis .................................................................................................. 90
4.4.5.6 de aard van parodontale infecties ................................................................................................................ 90
4.4.5.6 microscopisch onderzoek ............................................................................................................................. 91
4.4.5.7 kweekstudies of PCR onderzoek ................................................................................................................... 91
4.4.5.8 verschillende vormen van parodontitis ........................................................................................................ 92
4.4.5.9 speciële bacteriologie (vanbuiten kennen) ................................................................................................... 93
4.4.5.10 virulentie van paropathogenen bacterien .................................................................................................. 98
4.4.5.11 zijn alle paropathogene bacteriën normale mondbewoners? .................................................................. 100
4.5 VATBAARHEID VOOR PARODONTITIS (GENETISCHE FACTOREN)................................................................................. 101
4.5.1 inleiding ............................................................................................................................................ 101
4.5.2 epidemiologische aanwijzingen van de rol van erfelijke factoren bij parodontitis ........................... 104
4.5.3 het humaan genoom en genetische polymorfismen ........................................................................ 106
4.5.3 genetische parodontitis studies ........................................................................................................ 108
4.6 MODIFICERENDE FACTOREN: DIABETES, ROKEN, STRESS ......................................................................................... 109
4.6.1 diabetes ............................................................................................................................................ 109
4.6.2 roken ................................................................................................................................................. 111
4.6.3 psychische stress ............................................................................................................................... 115
4.7 IMMUNOLOGISCHE REACTIES BIJ PARODONTITIS ................................................................................................... 117
4.7.1 de parodontale infectie ..................................................................................................................... 120
4.7.2 de epitheliale barrière ....................................................................................................................... 121
4.7.3 de rol van het complement ............................................................................................................... 121
4.7.4 fagocytose ........................................................................................................................................ 121
4.7.5 de monocyt-macrofaag .................................................................................................................... 122
4.7.6 het cytokinenetwerk en andere onstekingsmediatoren ................................................................... 123
4.7.7 de rollen van de T-cellen ................................................................................................................... 124
4.7.8 de rollen van de B-cellen en de antilichaamproductie ...................................................................... 125
4.7.9 antilichaampresentatie ..................................................................................................................... 126
4.7.10 de pathogenese van parodontitis ................................................................................................... 127
4.8 PARODONTALE ONTSTEKINGEN: WEEFSELAFBRAAK................................................................................................ 129
4.8.1 afbraak van bind-steunweefsel en de cellen betrokken bij dit proces .............................................. 129
4.8.2 proteolytische enzymen .................................................................................................................... 131
4.8.3 hoe de afbraak stoppen? .................................................................................................................. 132
4.8.4 samenvatting .................................................................................................................................... 132
4.9 PARODONTITIS IN RELATIE TOT ALGEMENE GEZONDHEID ........................................................................................ 133
4.9.1 parodontitis en de acute fase reactie ............................................................................................... 134
4.9.2 parodontitis en cardiovasculaire aandoeningen .............................................................................. 135
4.9.3 parodontitis en zwangerschap.......................................................................................................... 142
4.9.4 parodontitis en diabetes mellitus ..................................................................................................... 143
4.9.5 parodontitis en rheumatoïde arthritis .............................................................................................. 147
4.9.6 parodontitis en respiratoire aandoeningen ...................................................................................... 148
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