influence of systemic conditions on the periodontium
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D E N T 3 7 1
D R . H I S H A M A L - S H O R M A N
INFLUENCE OF SYSTEMIC
CONDITIONS ON THE
PERIODONTIUM
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Endocrine disorderso Diabetes Mellitus
o Female sex hormones
o Corticosteroid hormones
o Hyperparathyroidism Hematological disorders
o Leukemia
o Anemia
o Thrombocytopenia
o Leukocytes disorderso Antibody deficiency disorders
Stress and psychosomatic disorders
Nutritional influences
Other systemic conditions
RELEVANT CONDITIONS
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DIABETES MELLITUS
The diseaseComplex group of metabolic disorders with a
common feature of impaired CARBOHYDRATEand
LIPIDmetabolism
Classes Type I
Type II Gestational
Others due to cancer, trauma ,etc..
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DIABETES MELLITUS
Diagnosis
oClinical picture
oBlood glucose levels
ComplicationsoMicrovascular
Retinopathy
Nephropathy
NeuropathyoMacrovascular
Cardiovascular
Cerebrovascular
o
Periodontal disease (the sixth complication!)
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DIABETES MELLITUS
DM pts (especially the un-controlled ) more
frequently have :
oMucosal drying and cracking
oBurning mouth and tongueoReduced salivary flow
oAlteration of the oral flora and predominance of
candida albicansangular cheilitis
They are at higher risk of developing periodontaldisease
Destruction is more severe in type I pts
Controlled pts have better periodontal health
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Mechanisms (1):
1. High levels of glucose in GCF and blood resultin change in oral flora and increasedperiodontal pathogens:oPorphyromonag gingivalis
oProvetella intermediaoAggrigatibacter actinomyceemcomitans
oCapnocytophaga
o
2. Defective PMN function in:oChemotaxis
oAdherence
oPhagocytosis
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3. Altered collagen metabolism and reduced woundhealing (chronic uncontrolled pts) :
o Increased collagenase activity
oDecreased collagen synthesis
o reduced fibroblast cell proliferation and growth
o reduced collagen and glycoseaminoglycansand other matrix components
4. Advanced Glycation Endproducts (AGEs)
oReduce collagen turn-over rateoCause hyperresponsive cellular state of
monocytes, macrophages and endothelial cells
o Increase production of interleukin-1 , TNF-,PG-E2 and other cytokines
Mechanisms(2):
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As a general rule:
Hormonal changes by themselves do NOTcause periodontal disease, they justaggravate the condition
Periodontal disease occurs only in thepresence of local factors and causativemicroorganisms
FEMALE SEX HORMONES
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PUBERTY
Exaggerated response to dental plaque
preventable condition
Clinically :
oMarked inflammation
oBluish red discoloration
o Edema
oGingival enlargement
Not always present
Reduced with age
Complete resolution requires removal of the local
factors
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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
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PREGNANCY
Generally, pregnancy does not cause gingivitis
It accentuates the gingival response to plaque andits 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
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Pregnancy tumor
PREGNANCY
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PREGNANCY
Pregnancy gingivitis
Linked to Prevotella intermedia
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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
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MENOPAUSE
Menopausal gingivostomatitisnot common
Due to the end of hormonal cycles in the body
Signs : gingiva and other oral mucosadry, 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
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CORTICOSTEROID HORMONES
Cortisone and ACTH have NO effect on
gingiva
Exogenous hormones have negative effect
on boneosteoporosis of alveolar bone and
bleeding in the periodontal ligament and CT
Stress increases circulating cortisol
reduced immune response to periodontal
bacteria
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PARATHYROIND HORMONE
Hyperparathyroidism produces:
oGeneralized bone demineralization
o Increased osteoclastic activity
oFormation of bone cysts
Oral changes include:
o Malocclusion and tooth mobility
o Radiographic evidence of alveolar osteoporosiso Widening of periodontal ligaments
o Absence of lamina dura
o Radiolucent cyst-like space
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HEMATOLOGIC DISORDERS
The importance of blood in the general well
being of humans
Functions :
oRBCsoxygenation of tissues and nutrition
oWBCsinflammatory reactions and body defense
oPlateletshemostasis and recruitment of cells
during wound healing
You may be the first to discover blood
disorders!
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HEMATOLOGIC DISORDERS -
LEUKEMIA
Malignant neoplasms of WBCs
Leukemic WBCs are abnormal and high innumber, therefore, the condition results in:
oReduced RBCsanemia and poor tissue
oxygenation
oNormal WBCs - infectionsoPlateletsbleeding disorders
Classified into: lymphocytic and myelocytic
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HEMATOLOGIC DISORDERS -
LEUKEMIA
Periodontal manifestations:
leukemic gingival infiltration
(enlargement), bleeding,
ulcerations and infectionsHighest incidence in acute-
monocytic leukemia (67%),
followed by acute-
myelocytic-monocytic (19%)and acute myelocytic
leukemia
Not seen in chronic leukemia
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HEMATOLOGIC DISORDERS
ANEMIA
Reduced RBCs and hemoglobin
Results from:
oBlood loss
oDefective formation
o Increased RBCs destruction
Types:
oPernicious anemia (impaired gastric absorption)o Iron-deficiency anemia (chronic bleeding)
oSickle-cell anemia (in blacks)
oAplastic anemia
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HEMATOLOGIC DISORDERS
ANEMIA
Clinical features:
o Red, smooth and shiny tongue.
o Increased pallor of the gingivao Ulceration of the oral mucosa
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HEMATOLOGIC DISORDERS
THROMBOCYTOPENIA
Petechiae and hemorrhage in the mouth
Spontaneous bleeding
Gingivae are swollen and fragile
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HEMATOLOGIC DISORDERS
LEUKOCYTE DISORDERS
Neutropeniasevere infections
Agranulosytosissevere infections
ChediakHigashi Syndromeaggressive
periodontitis
Lazy Leukocyte Syndromesevere infections -
aggressive periodontitis
Leukocyte Adhesion Deficiencysevere
infections and loss of teeth
Papillon-Lefevre Syndromeloss of teeth
Down Syndromeperiodontal pocket formation
and recession
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HEMATOLOGICAL DISORDERS
Cyclic nuetropenia
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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
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STRESS AND PSYCHOSOMATIC
DISORDERS
Stressed patients may :
oHave poor oral hygiene
oHave 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
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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 andincreased tooth mobility
Vitamin D
Vitamin E
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OTHER CONDITIONS
Protein deficiency
Hypophosphatasia
Congenital heart disease
Metal intoxication
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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 colleaguesin other specialties in dental and medical
professions
You may play a major role in educating patients and
helping them control their conditionsWhat if we improve the periodontal condition of
patients? Will this reduce the effect of systemic
conditions? SERARATE LECTURE
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