Influence of Systemic Conditions on the

Periodontium
 the relationship between periodontal disease and
systemic health is a two-way road, with systemic host
factors acting locally to reduce resistance to
periodontal destruction and the local bacterial
challenge generating widespread effects with the
potential to induce adverse systemic outcomes.
*Etiologic factors of periodontal disease have been
classified into local and systemic although their effects
are inter-related.

*Local factors are those in immediate environment of the

periodontium

*Systemic factors result from general condition of the

patient.
*Local factors mostly cause inflammation.
*Systemic factors modify the tissue response to local factors so
that the effect of local irritation may be aggravated

*Factors that reduce the defensive capacity of the tissues

include all systemic conditions that may disturb the tissue
response to irritation.
Systemic factors can act by either :
1-Reducing tissue resistance to plaque
(local) so resulting in periodontal
disease
or

2-By producing changes, as such, which

are termed as periodontal
manifestation of systemic disease.
 Systemic Factors In The Etiology Of Gingival And
Periodontal Diseases

1)Endocrine disorders
2)Haematologic disorders
3)genetic disorders
4) Stress and Psychomatic disorders
5)Nutritional deficiency
6)Effect of drugs
1)Endocrine disorders
Diabetes mellitus

Disease resulting from lack of insulin

 Low output of insulin from pancreas
 Unresponsiveness of peripheral tissues to insulin

Metabolic component:
 Increased blood glucose from lack of insulin.
 Changes in lipid protein metabolism

Vascular component:
 Atherosclerosis
 Microangiopathy affecting the kidneys and eyes
 What does insulin do?
▪ Transfers glucose from blood to insulin-dependent tissues.

▪ It is needed for muscle, fat, and liver to utilize glucose from the
blood.

▪ Regulates carbohydrates, fat, and protein metabolism.

▪ Stimulates the transfer of amino acids from blood to cells.

▪ When insulin is insufficient or the action of insulin is insufficient,

glucose accumulates in the tissue fluids and blood.
What is the result?

▪ Glycosuria and polyuria result due to the kidneys

not being able to reabsorb the excess glucose.

▪ Polydipsia is in response to fluid loss (polyuria).

▪ Polyphagia occurs to compensate for glucose loss,

but there is still weight loss.
 Uncontrolled diabetes (chronic hyperglycemia) is
associated with several long-term complications, including:

 microvascular diseases (retinopathy, nephropathy, or

neuropathy),
 macrovascular diseases (cardiovascular, cerebrovascular),
 increased susceptibility to infections
 Poor wound healing.
 There are two major types of diabetes, type 1 and type 2
 Type 1 diabetes mellitus, formerly insulindependent
diabetes mellitus (IDDM), is 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
 Type 2 diabetes mellitus, formerly non–insulin-
dependent diabetes mellitus (NIDDM), is caused by:

 peripheral resistance to insulin action

 impaired insulin secretion,
 increased glucose production in the liver
 Oral Manifestations

 Numerous oral changes have been described in

diabetic patients, including:
 cheilosis
 mucosal drying and cracking
 burning mouth and tongue
 diminished salivary flow
 alterations in the flora of the oral cavity, with greater
predominance of Candida albicans
 An increased rate of dental caries has also been
observed in poorly controlled diabetes
 These changes are not always present, are not specific,
and are not pathognomonic for diabetes.
 Furthermore, these changes are less likely to be
observed in well-controlled diabetic patients.
 Individuals with controlled diabetes have a normal
tissue response, a normally developed dentition, a
normal defense against infections, and no increase in
the incidence of caries
A variety of periodontal changes have been
described such as :

1-Severe gingival inflammation

2-Gingival enlargement ,sessile or
pedunculated gingival polyp

3-Deep periodontal pockets

A variety of periodontal changes have been described such as :

4-Frequent periodontal
abscesses

5- Increased bone loss with

increased tooth mobility
and greater loss of attachment.
A variety of periodontal changes have been described
such as :

6-Retarded post surgical healing

slow wound healing &susceptibility to infection in periodontal
surgery due to :
1}hyperglycemia which leads to reduction in phagocytosis .
2}vascular changes which lead to decreased mobilization of
neutrophils & decreased O2 tension
 diabetes mellitus does not cause gingivitis or
periodontitis,
 evidence indicates that it alters the response of the
periodontal tissues to local factors, hastening bone
loss and delaying postsurgical healing.
 Frequent periodontal abscesses appear to be an
important feature of periodontal disease in diabetic
patients
 Polymorphonuclear Leukocyte Function
 impaired chemotaxis
 defective phagocytosis
 impaired adherence

 As a result, the primary defense (PMNs) against

periodontal pathogens is diminished, and bacterial
proliferation is more likely
 Altered Collagen Metabolism

 Chronic hyperglycemia impairs collagen structure and

function, which may directly impact the integrity of
the periodontium.
 Decreased collagen synthesis, osteoporosis, as well as
a reduction in alveolar bone height has been
demonstrated in diabetic animals
 Chronic hyperglycemia adversely affects the synthesis,
maturation, and maintenance of collagen and
extracellular matrix.

 In the hyperglycemic state, numerous proteins and

matrix molecules undergo a nonenzymatic
glycosylation, resulting in accumulated glycation end-
products (AGEs)
 Collagen is cross-linked by AGE formation, making it
less soluble and less likely to be normally repaired or
replaced
 Cellular migration through cross-linked collagen is
impeded, and perhaps more importantly, tissue
integrity is impaired as a result of damaged collagen
remaining in the tissues for longer periods (i.e.
collagen is not renewed at a normal rate).

 As a result, collagen in the tissues of patients with

poorly controlled diabetes is older and more
susceptible to pathogenic breakdown (i.e., less
resistant to destruction by periodontal infections).
 AGEs play a central role in the classic complications of
diabetes and may play a significant role in the
progression of periodontal disease as well.

 Poor glycemic control, with the associated increase in

AGEs, renders the periodontal tissues more
susceptible to destruction.


 The cumulative effects of

 altered cellular response to local factors

 impaired tissue integrity
 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.
 In puberty and pregnancy, these changes are
characterized by nonspecific inflammatory reactions
with a predominant vascular component, leading
clinically to a marked hemorrhagic tendency
 Oral changes during menopause may include :

 thinning of the oral mucosa

 gingival recession
 xerostomia
 altered taste
 burning mouth
Gingiva in Puberty:
Clinical features:
▪ Pronounced inflammation.

▪ Bluish-red discoloration.

▪ Enlargement.
Gingiva in Puberty:
*There is increased response of gingival
reaction to local irritants.

▪Severity of gingival reaction reduces as

adulthood is approached, even when local
irritants are present.

▪Complete return to normal after their

removal.

▪With proper oral hygiene procedure, it

can be prevented
Gingival changes in pregnancy:
*Gingival changes are mainly due to increased levels of
progesterone.

*Pregnancy is a secondary modifying factors ,it does not alter

healthy gingiva
*It increases the response of gingival reaction to local irritants and
itself does not cause gingivitis.

Gingiva does not return to normal till local

irritants are removed.
Gingival changes in pregnancy:
Clinical features:
Gingival inflammation :
*The resulting gingivitis is essentially
hyperplasic although there's minimal
fibroblast proliferation ,there is marked
proliferation of the capillaries
(increased vascularity) leading to the
typically purple coloration of the gingival
papillae which are soft fragile, pits on
pressure, smooth shiny and tend to
bleed easily .
Clinical features:
Occasionally gingiva may enlarged
presents in either of two forms:
(1)Marginal Enlargement

(2)Tumor-like enlargement
 Hyperparathyroidism
 Parathyroid gland is significantly important in ( ca) metabolism by
parathyroid hormone (PTH)
 (PTH) maintains normal blood (ca) level in range of 9-11mg/dl
 Hyperparathyroidism caused by increased secretion of (PTH)
which affect the skeleton,
Clinical changes :
Malocclusion and tooth mobility.
Radiographic evidence of:
▪ Alveolar osteoporosis.
▪ Widening of periodontal space.
▪ Absence of lamina dura.
▪ Giant cell tumour.
 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

 Loss of the lamina dura and giant cell tumors in the
jaws are late signs of hyperparathyroid bone disease,
which in itself is uncommon

 Complete loss of the lamina dura does not occur often,

and clinicians may attach too much diagnostic
significance to it.
 Loss of lamina dura may also occur in Paget's disease,
fibrous dysplasia, and osteomalacia
 Reports have suggested that 25% to 50% of patients
with hyperparathyroidism have associated oral
changes.
 These changes include malocclusion and tooth
mobility, radiographic evidence of alveolar
osteoporosis with closely meshed trabeculae, widening
of the periodontal ligament space, absence of the
lamina dura , and radiolucent cystlike spaces.

 These cysts have been called brown tumors

 but they are not tumors. More accurately, these cysts
are reparative giant cell granulomas.

 In some cases these lesions appear in the periapical

region of teeth and can lead to a misdiagnosis of a
lesion of endodontic origin.
Good luck