Influence of Systemic conditions on the Periodontium

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1 Influence of Systemic conditions on the Periodontium Hamad Alzoman, BDS, M.S. Diplomate, The American Board of Periodontology Hamad Alzoman

2 Etiology Bacteria Host Time

3 Bacteria Host Time

4 Diabetes Smoking HIV infection Osteoporosis Periodontitis

5 Systemic conditions may have an effect on: Physiological response Vascular system Inflammatory response Immune system Tissue repair

6 What are the potential effects of systemic conditions on periodontium?

7 Systemic conditions have the potential to modify the: Susceptibility to disease Plaque microbiota Clinical presentation of periodontal disease Disease progression Response to treatment

8 Systemic condition that may have an influence on periodontal diseases includes: Smoking * Diabetes * Osteoporosis Pregnancy HIV infection Leukemia Nutrition Stress

9 Osteoporosis

10 Osteoporosis: A disease that causes bones to lose mass and break easily. Osteoporosis means porous bone

11 Osteoporosis can be associated with : Post-menopause ( estrogen deficiency) Smoking Low Calcium/vitamin D intake Glucocorticoid use

12 How does Osteoporosis affect periodontium : Weaker Alveolar bone Less resistance to periodontal disease Tooth loss

13 On the other hand, estrogen replacement therapy reduced tooth loss in postmenopausal women

14 Pregnancy

15 Pregnancy Pregnancy-associated gingivitis Pregnancy-associated pyogenic granuloma

16 Pregnancy-associated gingivitis : Prevalence: 35%-100% 4th to 8th months of gestation and then decrease in the last month of pregnancy Associated with high level of P. intermedia High levels of gonadotropins during the 1st trimester and high levels of estrogen & progesterone hormones during the 3rd trimester

17 Characteristic of pregnancy-associated gingivitis : Pronounced inflammatory response of gingiva Onset is in pregnant women Change in gingival color and contour Increase bleeding upon probing No attachment loss More pronounced in anterior area Interproximal areas more affected Reversible after child birth

18 How does estrogen and progesterone affect periodontium?

19 mechanisms : Subgingival Plaque Composition Anaerobic-to-aerobic ratio increases Higher concentrations of P intermedia (substitutes sex hormone for vitamin K growth factor) Maternal Immunoresponse Depression of cell-mediated immunity Decreased neutrophil chemotaxis Depression of antibody and T cell responses

20 mechanisms : Estrogen Increases cellular proliferation in blood vessels (known in the endometrium) Decreases keratinization Progesterone Increases vascular dilation and thus increases permeability (results in edema and accumulation of inflammatory cells) Increases proliferation of newly formed capillaries in gingival tissues (increased bleeding tendency) Alters rate and pattern of collagen production

21 Pregnancy-associated pyogenic granuloma : (Pregnancy Granuloma, Pregnancy tumor) Located mainly at the maxilla, in particular, anterior vestibular aspect red, pedunculated soft interdental tissue and is often covered with small fibrin spots

22 Pregnancy-associated pyogenic granuloma : Has initial rapid growth and rarely exceed 2 cm Bleed easily if disturbed Tendency to recur following incomplete removal Spontaneous regression postpartum

23 Puberty

24 Characteristics of Puberty- Associated Gingivitis 1. Plaque present at the gingival margin. 2. Pronounced inflammatory response of gingiva. 3. Must be circumpubertal 4. Change in gingival color. Mariotti A, Dental Plaque Induced Gingival Diseases. Ann Periodontol 1999;4:7-17

25 Characteristics of Puberty Associated Gingivitis 5. Change in gingival contour with possible modification of gingival size. 6. Increased gingival exudate. 7. Bleeding upon probing. 8. Absence of attachment loss. 9. Absence of bone loss. 10. Reversible following puberty. Marriotti 1999 Mariotti A, Dental Plaque Induced Gingival Diseases. Ann Periodontol 1999;4:7-17

26 Clinical manifestations Often an exaggerated inflammatory response to plaque and other irritations that would elicit a minor response. Inflammation including edema is seen often with a bluish red Caranza FA Jr.,Newman MG. Clinical Periodontology 8th ed.w. B. Saunders Company 1996; discoloration.

27 Clinical Manifestations The most frequent manifestation is bleeding at the interdental sites. Inflammation usually diminshes as the children approach adulthood The gingiva can completely return to normal by removing the local irritants.

28 Theories why children experience more gingivitis during puberty 1. Shift in the oral bacterial flora induced by increased amounts of sex hormones promoting more inflammation. 2. Imbalances in sex hormones may alter normal immune system function. 3. High levels of progesterone can increase vascular permeability increasing gingival exudate. 4. Improper oral hygiene leading to plaque build up.

29 Leukemia

30 Leukemia associated gingivitis : Variable oral manifestations in leukemic patients Significant diagnostic findings Minor tissue changes May appear prior to diagnosis or during active treatment Oral Presentation: Gingival Hyperplasia Pale gingiva Ulcerations Persistent bleeding Often painful.

31 Periodontal Manifestations of leukemia Gingival hyperplasia with hemorrhage

32 HIV infection

33 HIV infection Linear gingival erythema Necrotizing ulcerative periodontitis (NUP)

34 HIV infection Mixed evidence between severity of periodontitis and CD4+ counts

35 Linear gingival erythema -Erythematous gingival band along gingival margin. Does not respond to plaque/calculus removal

36 Necrotizing ulcerative periodontitis (NUP) Necrosis an ulceration of coronal part of interdental papilla and /or gingival margins Deep. Crater-like osseous lesions most often located interdentally Pain Mouth malodor (halitosis)

37 Nutrition

38 Malnutrition might influence progression of periodontal disease by affecting: Immune and inflammatory process (vit C,iron) Bone metabolism (Ca, Vit D) Collagen metabolism (Vit C, iron, zinc) Epithelial barrier function (Vit C, folic acid, zinc)

39 Calcium intake reduced dietary calcium intake and reduced total serum calcium levels are associated with increased risk for periodontal disease

40 Ascorbic acid (Vitamin C) intake Affect collagen metabolism Affect bone formation Increased permeability of the oral mucosa to endotoxins Increase bacterial pathogenicity Essential for microvasculature integrity Vitamin C deficiency (scurvy) associated with: Gingival swelling, hemorrhage, retarded wound healing

41 Carbohydrates intake Carbohydrates increase plaque accumulation on the tooth surface leading to periodontal disease

42 Stress

43 Stress Studies to date suggest that stress, distress, and inadequate coping are risk indicators for periodontal disease. Systemic diseases like diabetes, cardiovascular disease, preterm delivery, and osteoporosis may share stress as a common risk factor

44 Questions?

Epidemiology of Periodontal Diseases

Epidemiology of Periodontal Diseases Dania Al Agili, BDS, MS, MPH, DrPH CD 633 January 2009 Lecture Objectives 1. To know the definitions of prevalence and incidence in periodontitis. 2. To describe the