L4 50 5‫بريو س‬

Periodontics I/Lecture 4

Role of Systemic Diseases in the Etiology of Periodontal Diseases

Introduction
It is a well established fact that the primary etiological agent in periodontal diseases is bacterial plaque.
The toxins and enzymes produced by the bacterial plaque elicit inflammatory and immunologic changes
in the periodontal tissues at both cellular and molecular levels. These responses can be affected by a
variety of systemic factors that can alter the response of the tissue to plaque. Furthermore, certain
systemic disorders can have a direct effect on the periodontal tissues and these represent the periodontal
manifestations of systemic diseases. In general, these diseases do not initiate chronic destructive
periodontitis but may accelerate its progression and increase tissue destruction.

Theses systemic disorders can be categorized into:

1) Dietary and Nutritional Aspects

2) Hematological Disorders
3) Metabolic and Endocrine Disorders
4) Immunological disorders
5) Psychosomatic disorders

Dietary and Nutritional Aspects of Periodontal Disease

The vitality of periodontal tissues, in both health and disease depends strongly on the essential nutrients.
The epithelium of the dentogingival junction and the underlying connective tissues are the most dynamic
tissues.

The majority of opinions and research findings point to the following:

1) Nutritional deficiencies produce changes in the oral cavity.

2) There are no nutritional deficiencies that by themselves cause gingivitis or periodontal pockets.

The dietary and nutritional disorders classified into:

1) The Consistency of Diet

2) Protein Deficiency
3) Vitamins Deficiency (vitamin C and vitamin D)

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 The Consistency of Diet
From the viewpoint of promoting and maintaining gingival and periodontal health, it is often
stated that a firm and fibrous diet is more beneficial than an intake of soft and more loosely-
textured food.
Softer diets tend to produce greater deposits of plaque and an increase in plaque can be noticed
when the soft diet especially contains high proportion of sucrose.
Diets that are predominantly fibrous are considered advantageous as they possess the ability to
impart a natural cleansing action to the teeth and the periodontium.
A coarse diet requires vigorous mastication and the plaque that forms approximately tends to be
towards the cleansable buccal and lingual surfaces of the teeth.
However coarse and granular diets can predispose to direct traumatic injury to the supporting
tissues.

 Protein Deficiency
Proteins are constituents of the organic matrices of all the dental tissues including the alveolar
bone. The integrity of the periodontal ligament is also dependent upon proteins (amino acid).
Studies have indicated that on deprivation of proteins, extreme pathologic changes occur and
there is marked degeneration of periodontal support.

 Vitamins Deficiency
Vitamins are essential, biologically-active constituents of a diet which cannot be replaced by
other dietary components.

Vitamin C Deficiency

Its deficiency in humans result in scurvy, a disease characterized by hemorrhagic diathesis and
retardation of wound healing.

 Clinical Manifestation
1. Increased susceptibility to infection.
2. Impaired wound healing.
3. In severe cases, the gingiva becomes brilliant-red, tender and grossly swollen.
4. The spongy tissues are extremely hyperemic and bleed spontaneously.
5. Alveolar bone resorption with increased tooth mobility.

 Possible Etiologic Relationships between Ascorbic Acid and Periodontal Disease

1) Low levels of ascorbic acid influences the metabolism of collagen within the periodontium,
thereby affecting the ability of the tissue to regenerate and repair by itself.
2) It interferes with bone formation leading to the loss of the alveolar bone.
3) Increases the permeability of oral mucosa to tritiated endotoxin and inulin.

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 4) Increased levels of Ascorbic acid enhance both the chemotactic and migratory action of
leukocytes without influencing phagocytic activity.
5) Optimal level of Ascorbic acid is required to maintain the integrity of the periodontal
microvasculature as well as the vascular response to bacterial irritation and wound healing.
6) Depletion of vitamin C may interfere with the ecologic equilibrium of bacteria in plaque and
increases its pathogenicity.

Vitamin D deficiency

Vitamin D is essential for the absorption of calcium from the gastrointestinal tract and the
maintenance of calcium phosphorus balance.

Radiographically, there is a generalized partial to complete disappearance of lamina dura and

reduced density of supporting bone, loss of trabeculae, increased radiolucency of the trabecular
interstices and increased prominence of the remaining trabeculae.

Effects of Hematological Disorders on Periodontium

Disorders of the blood and blood forming tissue can have a profound effect on the periodontal tissues
and their response to bacterial plaque. The WBC disorders have the most pronounced effect on the
periodontal tissues. Disorders of hemostasis can be classified according to the underlying defect. There
can be a defect in the vascular constriction, platelet adhesion and aggregation, coagulation and
fibrinolysis.

Hematological disorders classified into:

1) Cyclic Neutropenia
2) Leukemia
3) Sickle cell anemia

 Cyclic Neutropenia

It is characterized by a cyclic depression of the PMN count in peripheral blood. The cyclic intervals are
usually between 19 and 21 days. Clinical problems include pyrexia, oral ulceration and skin infections.

 Periodontal manifestations
include oral ulceration, inflamed gingiva, rapid periodontal breakdown, and alveolar bone loss.
Bone loss is most obvious around the lower incisors and first permanent molars.

 Treatment:
plaque control, supportive measures like antiseptic mouth wash, antimicrobial therapy has been
proposed.

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  Leukemia

It is a malignant disease caused by proliferation of WBC forming tissue, especially those in bone
marrow. Acute leukemia is more frequent in people under 20 years of age. Chronic leukemia's occur in
over 40 years of age.

 Periodontal Manifestations

The major manifestations being gingival enlargement, gingival bleeding and periodontal infections. The
incidence and severity of these problems varies according to the type and nature of leukemia.

a. Gingival enlargement is primarily due to a massive leukemic cell infiltration into the gingival
connective tissue. The enlarged gingiva will hinder mechanical plaque removal; hence there will
be an inflammatory component enhancing this enlargement.
b. Gingival bleeding is a common oral manifestation of acute leukemia. The bleeding is secondary
to thrombocytopenia that accompanies leukemia.
c. Infections of the periodontal tissues secondary to leukemia can be of two types, either an
exacerbation of an existing periodontal disease or an increased susceptibility of the periodontium
to fungal, viral or bacterial infections.

 Treatment Plan for Leukemia Patients

1) Refer the patient for medical evaluation and treatment.
2) Prior to chemotherapy, a complete periodontal plan should be developed.
a. Monitor hematologic laboratory values.
b. Administer suitable antibiotics before any periodontal treatment.
c. Periodontal treatment consists of scaling and root planning; twice daily rinsing with
0.12 % chlorhexidine gluconate is recommended. If there is irregular bleeding time,
careful debridement with cotton pellets soaked in 3 % hydrogen peroxide is performed.

3) During the acute phase of leukemia:

a. Cleanse the area with 3 % hydrogen peroxide (H2O2) or 0.12 % chlorhexidine.
b. Carefully explore the area and remove any etiologic local factors.
c. Re-cleanse the area with 3 % H2O2.
d. Place a cotton pellet soaked in thrombin against the bleeding point.
e. Cover with gauze and apply pressure for 15 to 20 minutes.
f. Acute gingival or periodontal abscesses are treated by systemic antibiotics, gentle incision
and drainage or by treating with 3 % H2O2/0.12 % chlorhexidine gluconate.
g. Oral ulceration should be treated with antibiotics and bland mouth rinses.

4) In patient with chronic leukemia, scaling and root planning can be performed but periodontal
surgery should be avoided. Plaque control and frequent recall visits should receive particular
attention.

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  Sickle cell anemia

In this condition, the red blood cells undergo sickling when subjected to hypoxia. Hence patients with
sickle cell anemia are susceptible to infections. In some patients with sickle cell anemia, periodontal
disease may provide a sufficient inflammatory response to precipitate a sickling crisis.

Metabolic and Endocrine Disorders

The endocrine glands produce hormones that control metabolism and maintain hemostasis. Diabetes
mellitus is the main endocrine disorder that affects the periodontium. The sex hormone can alter the
response of periodontal tissues to plaque. Disorders of the pituitary, thyroid and adrenal glands have
little direct on the periodontal structures or in altering the host response to bacterial plaque.

Metabolic and endocrine disorders classified into:

1) Diabetes Mellitus
2) Gonads disorders

 Diabetes Mellitus

Studies suggested that diabetic is more susceptible to periodontal breakdown, which is characterized
by extensive bone loss, increased tooth mobility, widening of periodontal ligament space,
suppuration and abscess formation.

 Pathogenesis

There are several underlying factors that accompany diabetes mellitus which may account for the
apparent increased prevalence of periodontal disease in this condition. These factors can be considered
under the following headings:

1) Vascular changes include thickening and hyalinization of vascular walls.

2) Impairment of PMN function.
3) Alterations in the constituents and flow rate of crevicular fluid.
4) Changes in plaque micro flora.

 Treatment
a. Periodontal treatment in patient with uncontrolled diabetes is contraindicated.
b. If suspected to be a diabetic, following procedures should be performed:
1. Consult the patient’s physician.
2. Analyze laboratory tests, fasting blood glucose, postprandial blood glucose, glycated
hemoglobin, glucose tolerance test (GTT), urinary glucose.

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 3. If there is periodontal condition that requires immediate care, prophylactic antibiotics
should be given.
4. If patient is a ‘brittle’ diabetic, optimal periodontal health is a necessity. Glucose levels
should be continuously monitored and periodontal treatment should be performed when
the disease is in a well-controlled state. Prophylactic antibiotics should be stated 2 days
preoperatively, Penicillin is the drug of first choice.

 Guidelines
1) Clinician should make certain that the prescribed insulin has been taken, followed by a meal.
Morning appointments are ideal, after breakfast, because of optimal insulin levels.
2) After any surgical procedures, postoperative insulin dose should be altered.
3) Tissues should be handled as atraumatically and as minimally (less than 2 hours) as possible. For
anxious patients, if preoperative sedation is required, epinephrine concentration should not be
greater than 1:1, 00,000.
4) Diet recommendation should be made.
5) Antibiotic prophylaxis is recommended for extensive therapy.
6) Recall appointments and fastidious home oral should be stressed.

 Gonads

There are several types of gingival diseases in which modification of the sex hormones is considered
to be either an initiating or complicating factor; gingival alteration are associated with physiologic
hormonal changes with a predominant marked hemorrhagic tendency.

Gingivitis in Puberty

Pronounced inflammation, bluish-red discoloration, edema and enlarged gingiva may be seen.

 Treatment:

It is treated by scaling and curettage, removal of all sources of irritation and plaque control. In
severe cases, surgical removal of enlarged tissue may be required.

Gingival Changes Associated with Menstrual Cycle

There is increased prevalence of gingivitis, bleeding gingiva. Exudation from inflamed gingiva is
also increased, but the crevicular fluid flow is not affected. The salivary bacterial count is
increased. No active treatment is required.

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 Gingival Diseases in Pregnancy

Pregnancy accentuates the gingival response to plaque. The severity of gingivitis is increased
during pregnancy, beginning in the second or third month. It becomes more severe by the eighth
month and decreases during ninth month.

 Clinical Features
1) Pronounced base of bleeding.
2) Gingiva is bright-red to bluish-red.
3) Marginal and interdental gingiva is edematous, pits on pressure and sometime present raspberry-
like appearance.
4) Increased crevicular fluid flow, pocket depth and mobility are also seen.

 Pathogenesis
 It has been suggested that during pregnancy there is depression of maternal T-lymphocyte
response.
 Aggravation of gingivitis has been attributed principally to increased levels of progesterone
which produces dilatation and tortuosity of the gingival microvasculature, circulatory stasis and
increased susceptibility to mechanical irritation.

 Treatment:

Requires elimination of all local irritants that are responsible for precipitating gingival changes.
Marginal and interdental gingival inflammation and enlargement are treated with scaling and root
planning.

Treatment of tumor-like gingival enlargements consists of surgical excision, scaling and planning of
tooth surface.

In pregnancy emphasis should be on:

 Preventing gingival disease before it occurs.

 Treating existing gingival disease before it becomes worse.

Menopausal Gingivostomatitis

It occurs during menopause or in the postmenopausal period. Clinical manifestation include dry, shiny
oral mucosa, dry burning sensation of oral mucosa, abnormal taste sensation described as salty, peppery
or sour.

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 Acquired Immunodeficiency Syndrome
It is caused by a persistent HIV virus and is characterized by destruction of lymphocytes, rendering the
patient susceptible to opportunistic infections including destructive periodontal lesions.

 Clinical manifestations

HIV gingivitis: in HIV gingivitis persistent, linear, easily bleeding, erythematous gingivitis has been
described. Linear gingivitis lesions may be localized or generalized in nature. The erythematous
gingivitis may be limited to marginal tissue, or extend into attached gingiva in a punctuate or a diffuse
erythema or extend into alveolar mucosa. A severely destructive acutely painful necrotizing ulcerative
stomatitis has been reported.

HIV periodontitis: NUP (necrotizing ulcerative periodontitis) is characterized by soft tissue necrosis and
rapid periodontal destruction that results in marked interproximal bone loss. It is severely painful at
onset.

 Treatment:

Recommended management for linear gingival erythema is as follows:

1) Instruct the patient to perform meticulous oral hygiene.

2) Scale and polish affected areas and perform subgingival irrigation with chlorhexidine.
3) Prescribe chlorhexidine gluconate mouth rinse.
4) Reevaluation and frequent recall visits.
5) Systemic antibiotics such as metronidazole or amoxicillin should be prescribed for patients with
moderate to severe tissue destruction. Use of prophylactic antifungal medication should be
considered.

Treatment for necrotizing ulcerative periodontitis includes local debridement, scaling and root planning,
irrigation with Betadine solution and establishment of meticulous oral hygiene, including home use of
antimicrobial rinses. In severe NUP, antibiotic therapy is a must (metronidazole 400 mg thrice daily for
5 to 7 days).

Psychosomatic disorders
There are two ways by which psychosomatic disorders may be induced in the oral cavity, through the
development of habits injurious to the periodontium and by the direct effect of the autonomous nervous
system on the physiologic tissue balance.

However, under the condition of mental and emotional stress, the mouth may subconsciously become an
outlet for the gratification of basic drives in the adult. Gratification may be derived from neurotic habits,
which are potentially injurious to the periodontium.