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Relationship Between Periodontal And Systemic Disease Dr. Manal Abu Al Ghanam Many systemic diseases, disorders, and conditions have been implicated as risk indicators or risk factors in periodontal disease. Recent evidence suggests that periodontal infections can adversely affect systemic health with manifestations such as coronary heart disease, stroke, diabetes, preterm labor, low-birth-weight delivery, and respiratory disease. Endocrine Disorders and Hormonal Changes Diabetes Mellitus Female Sex Hormones Hyperparathyroidism Diabetes Mellitus A complex metabolic disorder characterized by chronic hyperglycemia. Diminished insulin production, impaired insulin action, or a combination of both result in the inability of glucose to be transported from the bloodstream into the tissues, which in turn results in high blood glucose levels and excretion of sugar in the urine. Diabetes Mellitus 1. 2. 3. 4. Uncontrolled diabetes (Chronic hyperglycemia) is associated with several long-term complications: Microvascular diseases . Macrovascular diseases . Increased susceptibility to infections. Poor wound healing. Diabetes Mellitus There are two major types of diabetes: 1. Type 1 diabetes mellitus (IDDM) caused by a cell-mediated autoimmune destruction of the insulin-producing beta cells of the islets of Langerhans in the pancreas, which results in insulin deficiency. Present with the symptoms traditionally associated with diabetes, including polyphagia, polydipsia, infections. polyuria, and predisposition to Diabetes Mellitus 2. Type 2 diabetes mellitus, (NIDDM) Is caused by peripheral resistance to insulin action, impaired insulin secretion, and increased glucose production in the liver. Occurs in obese individuals and can often be controlled by diet and oral hypoglycemic agents. Ketosis and coma are uncommon. Type 2 diabetes can present with the same symptoms as type 1 diabetes but typically in a less severe form. Diabetes Mellitus 1. 2. 3. 4. 5. 6. An additional category of diabetes is hyperglycemia secondary to other diseases or conditions: Gestational diabetes associated with pregnancy. Diseases that involve the pancreas and destruction of the insulin-producing cells. Endocrine diseases, such as acromegaly and Cushing's syndrome. Tumors. Pancreatectomy. Drugs or chemicals that cause altered insulin levels. Oral Manifestations 1. 2. 3. 4. 5. 6. 7. Cheilosis. Mucosal drying. Cracking. Burning mouth and tongue. Diminished salivary flow. Alterations in the flora of the oral cavity, with greater predominance of candida albicans, hemolytic streptococci, and staphylococci. An increased rate of dental caries has also been observed in poorly controlled diabetes. Influence of Diabetes on the periodontium 1. 2. 3. 4. 5. 6. A tendency toward enlarged gingiva. Sessile or pedunculated gingival polyps. Polypoid gingival proliferations. Abscess formation. Periodontitis (deep periodontal pockets, rapid bone loss) Loosened teeth. Influence of Diabetes on the periodontium Most striking changes in uncontrolled diabetes are: The reduction in defense mechanisms and the increased susceptibility to infections, leading to destructive periodontal disease. In fact, periodontal disease is considered to be the sixth complication of diabetes. Influence of Diabetes on the periodontium The increased glucose in the gingival fluid and blood of diabetic patients could change the environment of the microflora. Type 1 diabetes mellitus and periodontitis have been reported to have a subgingival flora composed mainly of Capnocytophaga, anaerobic vibrios, and Actinomyces species. Porphyromonas gingivalis, Prevotella intermedia, and Aggregatibacter actinomycetemcomitans, which are common in periodontal lesions of individuals without diabetes, are present in low numbers in those with the disease. Polymorphonuclear Leukocyte Function The increased susceptibility of diabetic patients to infection has been hypothesized as being caused by polymorphonuclear leukocyte (PMN) deficiencies resulting in impaired chemotaxis, defective phagocytosis, or impaired adherence. No alteration of immunoglobulin A (IgA), G (IgG), or M (IgM) has been found in diabetic patients Altered Collagen Metabolism Chronic hyperglycemia impairs collagen structure and function, which may directly impact the integrity of the periodontium. Altered collagen metabolism undoubtedly play a significant role in the susceptibility of diabetic patients to infections and destructive periodontal disease. Female Sex Hormones Gingival alterations during puberty, pregnancy, and menopause are associated with physiologic hormonal changes in the female patient. Puberty Puberty is often accompanied by an exaggerated response of the gingiva to plaque. Pronounced inflammation, edema, and gingival enlargement result from local factors that might ordinarily elicit a comparatively mild gingival response . As adulthood approaches, the severity of the gingival reaction diminishes, even when local factors persist. Menstruation During the menstrual period, the prevalence of gingivitis increases. Some patients may complain of bleeding gums or a bloated, tense feeling in the gums in the days preceding menstrual flow. The exudate from inflamed gingiva is increased during menstruation, suggesting that preexisting gingivitis is aggravated by menstruation. Pregnancy Pregnancy itself does not cause gingivitis. The hormonal changes of pregnancy accentuate the gingival response to plaque and modify the resultant clinical picture. No notable changes occur in the gingiva during pregnancy in the absence of local factors. Pronounced ease of bleeding is the most striking clinical feature. In some cases the inflamed gingiva forms discrete “tumorlike” masses, referred to as pregnancy tumors . Hormonal Contraceptives Hormonal contraceptives aggravate the gingival response to local factors in a manner similar to that seen in pregnancy and when taken for more than 1.5 years, increase periodontal destruction. Menopause 1. 2. 3. The usual rhythmic hormonal fluctuations of the female cycle are ended as estradiol ceases to be the major circulating estrogen. The gingiva and remaining oral mucosa are Dry and shiny. Vary in color from abnormal paleness to redness, and bleed easily. Fissuring occurs in the mucobuccal fold in some women. Menopause The patient complains of a dry, burning sensation throughout the oral cavity, associated with extreme sensitivity to thermal changes; abnormal taste sensations described as “salty,” “peppery,” or “sour”; and difficulty with removable partial prostheses. Hyperparathyroidism Parathyroid hypersecretion produces generalized demineralization of the skeleton, increased osteoclasis with proliferation of the connective tissue in the enlarged marrow spaces, and formation of bone cysts and giant cell tumors. The disease is called osteitis fibrosa cystica, or von Recklinghausen's bone disease. Loss of the lamina dura and giant cell tumors in the jaws are late signs of hyperparathyroid bone disease, which in itself is uncommon. Hyperparathyroidism 1. 2. 3. 4. 5. 6. 25% to 50% of patients with hyperparathyroidism have associated oral changes: Malocclusion. Tooth mobility. Radiographic evidence of alveolar osteoporosis with closely meshed trabeculae. Widening of the periodontal ligament space. Absence of the lamina dura. Radiolucent cystlike spaces . Bone cysts become filled with fibrous tissue with abundant hemosiderin-laden macrophages and giant cells. These cysts have been called brown tumors. Hyperparathyroidism Brown tumor in patient with hyperparathyroidism. A, Periapical radiograph of brown tumor in patient with hyperparathyroidism. B, Occlusal radiographic view of brown tumor. Note expansion of lingual cortical plate and movement of premolar. HEMATOLOGIC DISORDERS AND IMMUNE DEFICIENCIES Hematologic Disorders and Immune Deficiencies 1. 2. 3. Leukocyte (Neutrophil) Disorders. Leukemia. Antibody Deficiency Disorders. Hematologic Disorders and Immune Deficiencies Petechiae and ecchymosis observed most often in the soft palate area are signs of an underlying bleeding disorder. It is essential to diagnose the specific etiology to appropriately address any bleeding or immunological disorder. Leukocyte (Neutrophil) Disorders The PMN (neutrophil) in particular plays a critical role in bacterial infections because PMNs are the first line of defense . Quantitative deficiency of leukocytes (neutropenia, agranulocytosis) are typically associated with a more generalized periodontal destruction affecting all teeth. Leukemia The leukemias are malignant neoplasias of WBC precursors characterized by: (1) diffuse replacement of the bone marrow with proliferating leukemic cells. (2) abnormal numbers and forms of immature WBCs in the circulating blood. (3) widespread infiltrates in the liver, spleen, lymph nodes, and other body sites. Leukemia lymphocytic indicates that the malignant change occurs in cells that normally form lymphocytes. myelogenous indicates that the malignant change occurs in cells that normally form RBCs, some types of WBCs and platelets. The Periodontium in Leukemic Patients 1. 2. 3. 4. Oral and periodontal manifestations of leukemia may include: leukemic infiltration bleeding oral ulcerations infections. The expression of these signs is more common in acute and subacute forms of leukemia than in chronic forms. The Periodontium in Leukemic Patients Adult female with acute myelocytic leukemia Large ulcerations on the palate Antibody Deficiency Disorders. Agammaglobulinemia, or hypogammaglobulinemia, is an immune deficiency resulting from inadequate antibody production caused by a deficiency in B cells. The disease is characterized by recurrent bacterial infections (ear, sinus, and lung infections). Patients are also susceptible to periodontal infections. Aggressive periodontitis is a common finding in children. Genetic disorders Genetic disorders Genetic disorders that result in an inadequate number or function of circulating neutrophils. Severe periodontitis has been observed in individuals with primary and secondary neutrophil disorders. Genetic disorders Primary Neutrophil Disorders Neutropenia Secondary Neutrophil Impairment Down Syndrome Agranulocytosis Chédiak-higashi Syndrome Lazy Leukocyte Syndrome Papillon-lefèvre Syndrome Inflammatory Bowel Disease Papillon-Lefèvre Syndrome Characterized by hyperkeratotic skin lesions, severe destruction of the periodontium, and in some cases, calcification of the dura. The cutaneous and periodontal changes usually appear together between the ages of 2 and 4 years. The skin lesions consist of hyperkeratosis and ichthyosis of localized areas on palms, soles, knees, and elbows. Papillon-Lefèvre Syndrome Periodontal involvement consists of early inflammatory changes that lead to bone loss and exfoliation of teeth. Primary teeth are lost by 5 or 6 years of age. The permanent dentition then erupts normally, but within a few years, the permanent teeth are also lost because of destructive periodontal disease. At a very early age, usually 15 to 20 years, patients are often edentulous except for the third molars. These may be lost as well a few years after eruption. Tooth extraction sites heal uneventfully. Papillon-Lefèvre Syndrome Down Syndrome Periodontal disease in Down syndrome is characterized by formation of deep periodontal pockets associated with substantial plaque accumulation and moderate gingivitis. These findings are usually generalized, although they tend to be more severe in the lower anterior region. Stress and Psychosomatic Disorders Psychologic conditions, particularly psychosocial stress, have been implicated as risk indicators for periodontal disease. Some studies have failed to recognize a relationship between psychological conditions and periodontal disease despite specific efforts to identify them. Nutritional Influences The majority of opinions and research findings regarding the effects of nutrition on oral and periodontal tissues point to the following: 1 There are no nutritional deficiencies that by themselves can cause gingivitis or periodontitis. However, nutritional deficiencies can affect the condition of the periodontium and thereby may accentuate the deleterious effects of plaque-induced inflammation in susceptible individuals. There are nutritional deficiencies that produce changes in the oral cavity. These changes include alterations of tissues of the 2 lips, oral mucosa, gingiva, and bone. These alterations are considered to be periodontal and oral manifestations of nutritional disease. Medications Some medications prescribed to cure, manage, or prevent diseases may have an adverse effect on periodontal tissues, wound healing, or the host immune response. Bisphosphonates are a class of widely prescribed medications that have recently been associated with osteonecrosis of the jaw. Corticosteroids have long been prescribed to suppress the immune system in the control and management of autoimmune disease, in cancer treatment, and as an antirejection medication in transplant patients. Conclusion Dentists need to appreciate the wide range of systemic conditions that have periodontal implications to modify the treatment of affected patients, and in some cases, the dentist may be the first doctor to diagnose systemic disease based on its oral presentation. THANK YOU