INFLUENCE OF SYSTEMIC CONDITIONS ON THE PERIODONTIUM

DENT371 DR. HISHAM AL-SHORMAN

RELEVANT CONDITIONS
Endocrine disorders
o Diabetes Mellitus o Female sex hormones o Corticosteroid hormones o Hyperparathyroidism

Hematological disorders
o Leukemia o Anemia o Thrombocytopenia o Leukocytes disorders o Antibody deficiency disorders

Stress and psychosomatic disorders

Nutritional influences Other systemic conditions

DIABETES MELLITUS
The disease
Complex group of metabolic disorders with a common feature of impaired CARBOHYDRATE and LIPID metabolism

Classes
Type I Type II Gestational Others due to cancer, trauma ,etc..

DIABETES MELLITUS
Diagnosis
o Clinical picture o Blood glucose levels

Complications
o Microvascular
Retinopathy Nephropathy Neuropathy

o Macrovascular
Cardiovascular Cerebrovascular

o Periodontal disease (the sixth complication!)

DIABETES MELLITUS
DM pts (especially the un-controlled ) more frequently have :
o Mucosal drying and cracking o Burning mouth and tongue o Reduced salivary flow o Alteration of the oral flora and predominance of candida albicans angular cheilitis

They are at higher risk of developing periodontal disease Destruction is more severe in type I pts Controlled pts have better periodontal health

Mechanisms (1):
1. High levels of glucose in GCF and blood result in change in oral flora and increased periodontal pathogens: o Porphyromonag gingivalis o Provetella intermedia o Aggrigatibacter actinomyceemcomitans o Capnocytophaga o 2. Defective PMN function in: o Chemotaxis o Adherence o Phagocytosis

Mechanisms(2):
3. Altered collagen metabolism and reduced wound healing (chronic uncontrolled pts) : o Increased collagenase activity o Decreased collagen synthesis
o reduced fibroblast cell proliferation and growth o reduced collagen and glycoseaminoglycans and other matrix components

4. Advanced Glycation Endproducts (AGEs) o Reduce collagen turn-over rate o Cause hyperresponsive cellular state of monocytes, macrophages and endothelial cells o Increase production of interleukin-1 , TNF-, PG-E2 and other cytokines

FEMALE SEX HORMONES

As a general rule:

Hormonal changes by themselves do NOT cause periodontal disease, they just aggravate the condition
Periodontal disease occurs only in the presence of local factors and causative microorganisms

PUBERTY
Exaggerated response to dental plaque preventable condition
Clinically :
o Marked inflammation o Bluish red discoloration o Edema o Gingival enlargement

Not always present Reduced with age Complete resolution requires removal of the local factors

MENSTRUAL CYCLE

Generally, menstrual cycle is NOT accompanied by gingival disease However, some patients may complain of bleeding gums and tense feeling of the gums a few days before the cycle

PREGNANCY
Generally, pregnancy does not cause gingivitis It accentuates the gingival response to plaque and its clinical picture. Peak at first and third trimesters

Reduction of the inflammation starts 2 months postpartum. After 1 year, the gingival health is similar to other women who never had pregnancy

PREGNANCY
Pregnancy tumor

PREGNANCY
Pregnancy gingivitis

Linked to Prevotella intermedia

ORAL CONTRACEPTIVES
They affect the periodontium in a way similar to pregnancy, i.e. accentuates the gingival response to dental plaque When taken for more than 1.5 year, it increases periodontal destruction

MENOPAUSE
Menopausal gingivostomatitis not common
Due to the end of hormonal cycles in the body Signs : gingiva and other oral mucosa dry, shiny, varies in color and bleeds easily. Fissuring in the mucobuccal fold may be noticed Symptoms :pt complains of dry burning sensation of the oral mucosa associated with extreme sensitivity to thermal changes, abnormal taste and difficulty with removable partial dentures

CORTICOSTEROID HORMONES
Cortisone and ACTH have NO effect on gingiva
Exogenous hormones have negative effect on bone osteoporosis of alveolar bone and bleeding in the periodontal ligament and CT Stress increases circulating cortisol reduced immune response to periodontal bacteria

PARATHYROIND HORMONE
Hyperparathyroidism produces:
o Generalized bone demineralization o Increased osteoclastic activity o Formation of bone cysts

Oral changes include:

o Malocclusion and tooth mobility

o o o o

Radiographic evidence of alveolar osteoporosis Widening of periodontal ligaments Absence of lamina dura Radiolucent cyst-like space

HEMATOLOGIC DISORDERS
The importance of blood in the general well being of humans Functions :
o RBCs oxygenation of tissues and nutrition o WBCs inflammatory reactions and body defense o Platelets hemostasis and recruitment of cells during wound healing

You may be the first to discover blood disorders!

HEMATOLOGIC DISORDERS LEUKEMIA

Malignant neoplasms of WBCs Leukemic WBCs are abnormal and high in number, therefore, the condition results in:
o Reduced RBCs anemia and poor tissue oxygenation o Normal WBCs - infections o Platelets bleeding disorders

Classified into: lymphocytic and myelocytic

HEMATOLOGIC DISORDERS LEUKEMIA

Periodontal manifestations: leukemic gingival infiltration (enlargement), bleeding, ulcerations and infections Highest incidence in acutemonocytic leukemia (67%), followed by acutemyelocytic-monocytic (19%) and acute myelocytic leukemia Not seen in chronic leukemia

HEMATOLOGIC DISORDERS

ANEMIA
Reduced RBCs and hemoglobin Results from:
o Blood loss o Defective formation o Increased RBCs destruction

Types:
o Pernicious anemia (impaired gastric absorption) o Iron-deficiency anemia (chronic bleeding) o Sickle-cell anemia (in blacks) o Aplastic anemia

HEMATOLOGIC DISORDERS

ANEMIA
Clinical features:
o Red, smooth and shiny tongue. o Increased pallor of the gingiva o Ulceration of the oral mucosa

HEMATOLOGIC DISORDERS THROMBOCYTOPENIA

Petechiae and hemorrhage in the mouth

Spontaneous bleeding
Gingivae are swollen and fragile

HEMATOLOGIC DISORDERS LEUKOCYTE DISORDERS

Neutropenia severe infections Agranulosytosis severe infections Chediak Higashi Syndrome aggressive periodontitis Lazy Leukocyte Syndrome severe infections aggressive periodontitis Leukocyte Adhesion Deficiency severe infections and loss of teeth Papillon-Lefevre Syndrome loss of teeth Down Syndrome periodontal pocket formation and recession

HEMATOLOGICAL DISORDERS

Cyclic nuetropenia

STRESS AND PSYCHOSOMATIC DISORDERS

NUG trench mouth
The effect of stress on periodontium is related to the type of stress and the ability of the patient to cope, i.e. the more the patient feels helpless, the more the periodontal destruction

Examples: financial crises, divorce, loss of family member, etc

STRESS AND PSYCHOSOMATIC DISORDERS

Stressed patients may :
o Have poor oral hygiene o Have clenching and grinding o Smoke more frequently o Less likely seek professional care

Stress also affects the immune response:

o Production of cortisol, resulting in reduced immune response by inhibiting:
o Neutrophil activity o IgG production o Salivary IgA

o Increased secretion of neurotransmitters which leads to increased tissue destruction

NUTRITIONAL INFLUENCES
Vitamin A : dermatological and mucosal health Vitamin B complex (especially B12, Folic Acid) Vitamin C (ascorbic acid) deficiency and scurvy Ascorbic acid is essential for collagen synthesis Periodontal manifestation: hemorrhagic lesions, impaired healing, gingival edema and increased tooth mobility Vitamin D Vitamin E

OTHER CONDITIONS

Protein deficiency Hypophosphatasia Congenital heart disease Metal intoxication

WHAT IS THE FINAL CONCLUSION?

The mouth could be a true mirror of the general health You may be the first to discover medical conditions You need to learn how to cooperate with colleagues in other specialties in dental and medical professions You may play a major role in educating patients and helping them control their conditions What if we improve the periodontal condition of patients? Will this reduce the effect of systemic conditions? SERARATE LECTURE