MAMATA

DENTAL

COLLEGE

DEPARTMENT OF PERIODONTICS

GUIDED BY Dr.C.SRIKANTH
M.D.S

Presented by KUNAL SINGH Roll no 07 Final B.D.S (31 Batch)

CONTENTS
 Introduction  Pathology of   

 

periodontitis Focal infection theory revisited Evidence-based clinical practice Subgingival environment as reservoir of bacteria Periodontal diseases and coronary heart diseases Periodontal disease and stroke

 Periodontal disease and diabetes mellitus  Periodontal disease and pregnancy outcome  Periodontal disease and chronic obstructive pulmonary disease  Periodontal disease and acute respiratory infection  Periodontal medicine in clinical practice  Summary  Bibliography

 Periodontal disease is an infectious

disease ,but environmental, physical, social & host cell may affect the modify disease expression. affect the initiation & progression of gingivitis & periodontitis.

 Certain systemic condition clearly may

 Systemic disorder affecting

neutrophil, monocytes / macrophages & lymphocytes function results in altered function or activity of host inflammatory mediators.

PATHOLOGY OF PERIODONTITIS Non specific accumulation of bacterial plaque was once thought to be the cause of periodontal destruction,but it is now recognised that periodontitis is an infectious disease associated with a small number of predominently gramnegative organisms that exist in a sub-gingival biofilm. The response to periodontal treatment may vary depending on the wound healing capacity & susceptibility of the host to further disease progression.

 Resent evidence suggest that periodontal

infection may significantly enhance the risk for certain systemic diseases.
 Condition in which the influences of

periodontal infection are documented include coronary heart disease (CHD) & CHD related events such as angina,infarction,atherosclerosis,stroke ,diabetes mellitus,low birth weight delivery & respiratory such as chronic obstructive pulmonary disease.

FOCAL INFECTION THEORY REVISED

 In 1900 william hunter,a british physician,

first developed the idea that oral organism were responsible for a wide range of systemic condition that were not easily recognised as being infectious in nature.
 In addition to caries,pulp necrosis, &

periapical abcess,hunter also identified gingivitis & periodontitis as foci of infection.

 Hunter belived that teeth were liable to

septic infection primarily because of there sructure & there relationship to alveolar bone.
 He also belived that oral organism had

specific action on different tissue & that these organisms acted by producing toxins,resulting in low grade subinfectionwhich produced systemic effects over prolonged period.

 Hunter theory became widely accepted in

Britain & eventually the United states,leading to wholesale extraction of teeth.

 Hunter & other advocates of the theory were

unable to explain how focal oral sepsis produced these systemic maladies..

EVIDENCE BASED CLINICAL PRACTICE

SUBGINGIVAL ENVIRONMENT AS RESERVOIR OF BACTERIA

 The subgingival micrbiotain patient with

periodontitis provides a significant & persistent gram-negative bacterial challenge to the host.

 These organism & there products such as

lipopolysacharide have ready access the periodontal tissue & to the circulation via the sulcular epithelium,which frequently ulcerated & discontinuous.

 This host response may offer explanatory

mechanisms for the interaction between periodontal infection and a variety of systemic disorders.

PERIODONTAL DISEASE & CHD/ATHEROSCLEROSIS

 To further explore the periodontal disease &

CHD/atherosclerosis association,investigators have studied specific systemic disorders & medical outcomes to determine their relationship to periodontal status.

 CHD related events are a major cause of

death.

 Localised infection resulting in a chronic

inflammatory reaction has been suggested as a mechanism underlying CHD in these individual.
 This association between poor dental health &

MI was independent of known risk factor for heart disease such as age,cholesterol levels,hypertension,diabetes & smoking.

 Cross-sectional studies thus suggest a

possible link between oral health & CHD; however,such studies cannot determine causality in this relationship.
 Bacterial infection have significant effects

on the endothelial cells,blood coagulation,lipid metabolism & monocytes/macrophages.

 Longitudinal studies provides compelling

data on this relationship.

 In a prospective study of a national sample

of adults subject with periodontitis had a 25% increase in the risk for CHD compared with those with no or minimal periodontal disease,after adjusting for other known risk factors.

 In another large prospective study,1147 men

followed for 18 years.

 During that time 207 men (18%) developed

CHD.

 The extent of sites with probing depth greater

than 3mm was strongly related to the incidence of CHD.

 Subject with probing depths greater than

3mm on at least half their teeth had a twofold increased risk,where those with probing depth greater than 3mm on all teeth had more than the threefold increased risk of CHD.
 Janket et al. performed a meta-analysis of

periodontal disease as a risk factor for future cardiovascular events & found an overall 19% increased risk of such events such individual with periodontitis.

EFFECT OF PERIODONTAL INFECTION

 Periodontal infection may affect the onset or

progression of atherosclerosis & CHD through certain mechanisms. ISCHEMIC HEART DISEASE
 It is associated with the processes with

atherosclerosis & thrombogenesis.

 Increased viscosity of blood may promote

major ischemic heart disease & cerebrovascular accident by increase the risk of thrombus formation.
 Elevated WBC count is also a predictor of

heart disease & stroke & circulating leukocytes may promote the occlusion of blood vessels.

SYSTEMIC INFECTION
 It is known to induce a hypercoagulablre

state & to increase blood viscosity.

 Thus periodontal infection may also

promote increased blood viscosity & thrombogenesis,leading to an increased risk for central & peripheral vascular disease.

DAILY ACTIVITY
 Routine daily activities such as mastication

& oral hygiene procedures result in frequent bacteremia with oral organisms.
 Periodontal disease may predispose the

patient to an increased incidence of bacteremia,includiing the presence of virulent gram-negative organisms associated with periodontitis.

 The periodontium when affected by

periodontitis,also act as reservoir of endotoxin from gram-negative organisms.

 Endotoxin can pass readily in to the

systemic circulation during normal daily function,precipitating many negative cardiovascular effects.

THROMBOGENESIS
 Platelet aggregation play a major role in

thrombogenesis & most cases of acute MI are precipitated by thromboembolism.

 Aggregation of platelets is induced by the

platelet aggregation associated protein exposed on some strains of these bacteria.

 Platelet accumulation also occurred in the

lungs leading to tachypnea.

 Thus periodontitis associated bacteremia with

certain strains of S.sanguis & P.gingivalis may promote acute thromboembolism events through interaction with circulating platelets.

ATHEROSCLEROSIS
 It is a focal thickening of the arterial

intima,the innermost layer lining the vessel lumen & the media,the thick layer under the intima consisting of smooth muscle,collagen,& elastic fibers.

 Atheromatous plaque formation &

thickening of the vessel wall narrow the lumen & dramatically decrease blood flow through the vessel.

 The thrombus may

separate from the vessel wall & form an embolus,which may also occlude vessel,again leading to acute events such as MI or cerebral infarction .

PERIODONTAL INFECTION ASSOCIATED WITH STROKE

 In case control sudies,poor dental health was a

significant risk factor for cerebrovascular ischemia.

 In one study,bleeding on

probing,suppuration,subgingival calculus,& the number of periodontal or periapical lesion were greater in male patients.

 This study supports an association between

poor oral health & stroke in men under age 50.

 In another study,men & women age 50 &

older who had a stroke had significantly more severe periodontitis & more periapical lesions than non stroke control.

 Furthermore,periodontal infection may

stimulate a series of indirect systemic effects such as elevated production of fibrinogen & CRP which serve to increase the risk of stroke.
 Finally bacteremia with PAAP-positive

bacterial strain from the supragingival & subgingival plaque can increase platelet aggregation contributing the thrombus formation & thromboembolism leading to stroke.

PERIODONTAL DISEASE AND DIABETES

 It is clear from epidemiologic research that

diabetes increases the risk for & severity from periodontal diseases.
 The increased prevalence & severity of

periodontitis typically seen in patient with diabetes,especially those with poor metabolic control,led to the designaation of periodontal disease as the sixth complication diabetes.

The following questions remains :

 Does the presence or severity of periodontal

disease affect the metabolic state in diabetic patient ?

 Does periodontal treatment aimed at

reducing the bacterial challenge & minimizing the inflammation have a measurable effect on glycemic control ?

COMPLICATION OF DIABETES MELLITUS

     

Retinopathy Nephropathy Neuropathy Macrovascular disease Altered wound healing Periodontal disease

 In diabetic patients with periodontitis

periodontal therapy may have beneficial effect on glycemic control.

 This may be especially true for patient with

relatively poor glycemic control & more advanced periodontal destruction before treatment.

 In a more recent evaluation of scaling & root planning combined with systemic doxycycline therapy for 2 weeks type 1 diabetic patient with improved periodontal health also had significant improvement in glycemic control.

 These studies suggest that the combination

of subgingival mechanical debridement & systemic doxycycline may result in short term improvement in glycemia in diabetic patient with severe periodontitis & poor metabolic control.

 The mechanism by which adjunctive

antibiotics may include positive changes in glycemic control when combined with mechanical debridement are unknown at this time.

PERIODONTAL INFECTION ASSOCIATED WITH GLYCEMIC CONTROL IN DIABETES

PERIODONTAL DISEASE & PREGNANCY OUTCOME

 Low birth weight infant (<2500g at birth)

are 40 times more likely to die in the neonatal period than normal birth weight infants.
 The primary cause of LBW deliveries is

preterm or premature rupture of membrane

BACTERIAL VAGINOSIS
 It is the most common vaginal disorder in

women of reproductive age.

 It is caused by changes in the vaginal

microflora in which normally predominant facultative lactobacilli are replaced by Gardnerella vaginalis anaerobic organism including species of prevotella bacteroides, peptostreptococcus porphyromonas.

 The frequency of F.nucleatum detection

suggests other possible routes of infection.

 Some investigators have suggested infection

by a hematogenous route from a location in which the organism is often detected.

 F.nucleatum is a common oral species highly

prevalent in patient with periodontitis & could reach the amniotic fluid by hematogenesis spread from the oral cavity.

ROLE OF PERIODONTITIS
 Periodontitis is a remote gram-negative

infection that may play a role in LBW infants.

 P.gingivalis implanted in subcutaneous

chamber during gestation caused significant increases in TNF- levels.

 These data suggest that a

remote,nondisseminated infection with P.gingivalis may result in abnormal pregnancy outcomes in this model.
 Decreased fetal birth weight & increased fetal

death were also seen after intravenous injection with LPS derived from P.gingivalis.

 This effect was greatly increased when

P.gingivalis LPS was administrated before mating & during gestation,indicating that repeated immunization with P.gingivalis LPS does not provide protection during pregnancy,but potentiates the negative effects of LPS exposure during gestation.

 In cross sectional

study,women having LBW infants had significantly higher level of actinobacilus actinomycetemitans Tannerella denticola in there subgingival plaque than did the control women having NBW infants.

 Thus women having LBW infants have a

higher prevalence of severity of periodontitis,more gingival infflamation,higher level of putative periodontal pathogen, & an elevated subgingival inflammatory response compared with women having NBW infants.
 Periodontal disease may also increase the risk

for preclampsia,this hypertensive disorder effect about 5-10% of pregnancies & a major cause of perinatal & maternal morbidity.

PERIODONTAL DISEASE & CHRONIC OBSTRUCTIVE PULMONARY DISEASE(COPD)

 COPD charecterized by airflow obstruction

resulting from chronic bronchitis or emphysema.

 COPD shares similar pathogenic

mechanisms with periodontal disease.

 In both diseases a host inflammatory

response is mounted in response chronic challenge.

 Less is known about the clinical

relationship between periodontal disease COPD compared with CHD & other systemic conditions.

PERIODONTAL DISEASE & ACUTE RESPIRATORY INFECTIONS

 The upper respiratory passages are often

contaminated with organisms derived from the oral,nasal, & pharyngeal region.
 Pneumonia is an infection of the lungs

caused by bacteria,virus,fungi or mycoplasma & is broadly categorised as either community acquired or hospitalised acquired pneumonia.

 Community acquired bacterial pneumonia

is caused primarily by inhalation & infectious aerosols or by aspiration of oropharyngeal organisms.

 Streptococcus pneumoniae & haemophilus

influanzae is most common although numerous other species may be found including anaerobic bacteria.

 The same cannot be said for individuals in

the hospital settings.

 Hospital acquired bacterial pneumonia has a

very high morbidity & mortality rate.

 Although nosocomial pneumonia is most

often caused by gram-negative aerobic organisms may cases are the result of infection by anaerobic bacteria.

 PRPs may also originates in the oral

cavity,with dental plaque serving as a reservoir of these organisms.

 Poor oral hygiene is the common in the

hospital & nursing home settings.

 In a systemic review used to improve oral

hygiene such as mechanical tooth brushing & chemical anti-microbial rinses have the potential to decrease the risk of nosocomial pneumonia.

PERIODONTAL DISEASE & SYSTEMIC HEALTH

 Proper use of the knowledge of potential

relationship between periodontal disease & systemic health requires the dental professional to expand his or here horizons to step back from the technically demanding aspects of dental art & to recognize the oral cavity as one of many interrelated organ systems.

 Periodontitis is a gram-negative infection

resulting in a severe inflammation with potential intravascular dissemination of micro-organisms & there products through out the body.
 However periodontitis tend to be a silent

disease until destruction results in acute symptoms.

PATIENT EDUCATION
 Patient education is priority.  Patient education efforts in the realm of

periodontal medicine must emphasize the nature of periodontal infection,the increased risk for the systemic disease associated with the infection & the biologically pluasible role periodontal infection play an systemic disease.  Enhanced community awareness may be derived from newspapers , magazines & other lay sources.

SUMMARY
 The emerging field of periodontal

medicine offer new insights in to the concept of the oral cavity as one system interconnected with the whole human body , for many years the dental profession has recognised the effects of systemic condition on the oral cavity.

BIBLIOGRAPHY
 Carranzas Clinical Periodontology
x

Tenth Edition