013.systemic diseases in the etiology of periodontal disease

1. Dr Jaffar Raza Page 1
Systemic Diseases in the etiology of PDD
primary etiological agent in periodontal disease is bacterial plaque.
systemic factors that can alter the response of the tissue to plaque.
certain systemic disorders can have a direct effect on the periodontal tissues
and these represent the periodontal manifestations of systemic diseases.

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DIETARY AND NUTRITIONAL ASPECTS OF PERIODONTAL DISEASE
The Consistency of Diet
Firm and fibrous diet  beneficial
Softer diet  greater deposits and increase in plaque
A coarse diet, requires vigorous mastication

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Protein Deficiency and Periodontal Disease
The integrity of the periodontal ligament is also dependent upon proteins
Deprivation of protien  marked degeneration of periodontal support
Vitamins and Periodontal Disease
Vitamin C
Its deficiency in humans results in scurvy, a disease characterized by
hemorrhagic susceptability and retardation of wound healing.

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Clinical Manifestations
1. Increased susceptibility to infections.
2. Impaired wound healing.
3. Bleeding and swollen gums.
4. Mobile teeth.

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Periodontal Features of Scurvy
chronic gingivitis which can involve the free gingiva, attached gingiva and
alveolar mucosa
gingiva becomes brilliant-red, tender and swollen
The spongy tissues are extremely hyperemic and bleed spontaneously.
the tissues attain a dark blue or purple hue.
Alveolar bone resorption with increased tooth mobility.

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Vitamin D Deficiency
Vitamin D is essential for the absorption of calcium from the gastrointestinal
tract and the maintenance of calciumphosphorus balance.
Radiographically, there is a generalized partial to complete disappearance of
the lamina dura
Reduced density of supporting bone.

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Vitamin E
vitamin E acts as a antioxidant
plays an important role in maintaining the stability of cell membranes
protecting blood cells against hemolysis.
interfere with the production of prostaglandins.

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Vitamin A
It is essential for growth, differentiation and maintenance of epithelial tissues
For bone growth and embryonic development.
Vitamin B-Complex
Oral changes common to—Vitamin B-complex deficiencies are
gingivitis,
glossitis,
glossodynia,
angular cheilitis
inflammation of the entire oral mucosa

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EFFECTS OF HEMATOLOGICAL DISORDERS ON PERIODONTIUM
Disorders of the blood and blood forming tissues can have a profound effect
on the periodontal tissues and their response to bacterial plaque.
There can be a defect in the vascular constriction, platelet adhesion and
aggregation, coagulation and fibrinolysis

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White Blood Cell Disorders
The WBC’s disorders that affect the periodontium can be categorized as either
a disorder of numbers or defect in function.
Neutropenias
a. Cyclic neutropenia.
b. Chronic benign neutropenia of childhood.
c. Benign familial neutropenia.
d. Severe familial neutropenia.
e. Chronic idiopathic neutropenia.

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Periodontal manifestations of neutropenias
oral ulceration,
inflamed gingiva,
rapid periodontal breakdown,
alveolar bone loss.
bleeding on probing
areas of desquamation,
varying degrees of gingival recession
pocketing
edematous and bright-red appearance of gingiva
persistant recurrent infections throughout life

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Treatment:
Plaque control,
supportive measures like antiseptic mouth wash,
antimicrobial therapy

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Leukemia
malignant disease caused by proliferation of
those in bone marrow.
Acute leukemia is more frequent in people under 20 years of age.
Chronic leukemia’s occur in people over 40 years of age.
Periodontal Manifestations
1..gingival enlargement,
2..gingival bleeding
3..periodontal infections.
malignant disease caused by proliferation of WBC forming tissue
leukemia is more frequent in people under 20 years of age.
leukemia’s occur in people over 40 years of age.
Periodontal Manifestations
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WBC forming tissue, especially
leukemia is more frequent in people under 20 years of age.

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a. Gingival enlargement is due to a massive leukemic cell infiltration into the
gingival connective tissue.
The enlarged gingiva will hinder mechanical plaque removal
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,
1.. exacerbation of an existing periodontal disease
2.. increased susceptibility of the periodontium to fungal, viral or bacterial
infections.

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Treatment Plan for Leukemic Patients
1. Referral 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. scaling and root planing + 0.12 percent chlorhexidine gluconate
3. During the acute phases of leukemia:
a. Cleanse the area with 3% (H2O2) or 0.12% chlorhexidine.
b. remove any etiologic local factors.
c. Re-cleanse the area with 3 percent 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.

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f. Acute gingival or periodontal abscesses are treated by systemic antibiotics,
gentle incision and drainage or by treating with 3% H2O2/0.12% chlorhexidine
g. Oral ulcerations should be treated with antibiotics and bland mouth rinses.
4. In patients with chronic leukemia, scaling and root planing can be performed
but periodontal surgery should be avoided.

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Thrombocytopenic Purpura
characterized by a low platelet count
Prolonged bleeding time
Prolonged clotting time
Clinical manifestation
spontaneous bleeding into skin or mucous membranes.
Petechiae and hemorrhagic vesicles occur in the oral cavity.
Gingiva is swollen, soft and friable.
Bleeding occurs spontaneously
Thrombocytopenic Purpura
characterized by a low platelet count
spontaneous bleeding into skin or mucous membranes.
and hemorrhagic vesicles occur in the oral cavity.
swollen, soft and friable.
Bleeding occurs spontaneously
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Treatment
1. Physician referral for a definitive diagnosis.
2. Oral hygiene instructions.
3. Prophylactic treatment of potential abscesses.
4. No surgical procedures are indicated unless platelet count is at least 80,000
cells/mm3.
5. Scaling and root planning.
Disorders of WBC Function
Chédiak-Higashi Syndrome
Lazy Leukocyte Syndrome
Chronic Granulomatous Disease

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METABOLIC AND ENDOCRINE DISORDERS
Diabetes Mellitus and Periodontal Disease
diabetic patient 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.

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Pathogenesis
1. Vascular changes:
thickening and hyalinization of vascular walls.
swelling and occasional proliferation of the endothelial cells
changes in the capillary basement membrane may have an inhibitory effect on
the transport of oxygen, white blood cells, immune factors and waste products

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2. PMNL’s function
Reduced Phagocytosis
Reduced intracellular killing
Reduced adherence
Impaired chemotaxis
3. crevicular fluid:
Alterations in the constituents and flow rate of crevicular fluid is noted

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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, FBS, RBS and GTT
3. prophylactic antibiotics should be given.
4. Glucose levels should be continuously monitored and periodontal treatment
should be performed when the disease is in a wellcontrolled state.
5.Prophylactic antibiotics should be started 2 days preoperatively

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Thyroid Gland
Hypothyroidism leads to cretinism in children and myxedema in adults.
There are no notable periodontalchanges.
Treatment
1. Patients with thyrotoxicosis should not receive periodontal therapy until the
condition is stabilized.
2. Medications such as epinephrine, atropine should be given with caution.
3. caution with administration of sedatives and narcotics because of their
diminished ability to tolerate drugs.

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Pituitary Gland
Hyperpituitarism causes enlarged lips
localized areas of hyperpigmentation.
It is also associated with food impaction
hypercementosis is seen.
Hypopituitarism leads to crowding and malposition of teeth.

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Parathyroid Glands
Parathyroid hypersecretion produces generalized demineralization of the
skeleton.
Oral changes include malocclusion and tooth mobility,
radiographically  alveolar osteoporosis, widening of the periodontal space
and absence of lamina dura.
Treatment:
Routine periodontal therapy must be instituted but the dental practitioner
must be attuned to the oral and dental changes.

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Sex Harmones
There are several types of gingival diseases in which
hormones is considered to be either
Gingivitis in Puberty
Pronounced inflammation,
bluish-red discoloration,
edema
enlarged gingiva may be seen
There are several types of gingival diseases in which modification of the sex
hormones is considered to be either an initiating or complicating factor
enlarged gingiva may be seen
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modification of the sex
an initiating or complicating factor.

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Gingival Changes Associated with Menstrual Cycle
There is increased prevalence of gingivitis,
bleeding gingiva.
inreased Exudation from inflamed gingiva
crevicular fluid flow is not affected.
The salivary bacterialcount is increased.

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Menopausal Gingivostomatitis
Clinical manifestations include
dry, shiny oral mucosa,
dry burning sensation of oral mucosa,
abnormal taste sensation

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Gingival Diseases in Pregnancy
Clinical Features
1. Pronounced bleeding.
2. Gingiva is bright-red to bluish
3. Marginal and interdental gingiva is
sometime presents raspberry
4. depression of maternal T-
6. Increased crevicular fluid flow
Gingival Diseases in Pregnancy
red to bluish-red.
3. Marginal and interdental gingiva is edematous, pits on pressure
raspberry-like appearance.
-lymphocyte response.
crevicular fluid flow, pocket depth and mobility are also seen.
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pressure and
are also seen.

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Treatment:
Elimination of all local irritants
Treatment of tumor-like gingival enlargements consists
scaling and planing of tooth surfaces.
In pregnancy emphasis should be on:
• Preventing gingival disease bef
• Treating existing gingival disease before it becomes
mination of all local irritants by scaling and root planing.
gingival enlargements consists of surgical
scaling and planing of tooth surfaces.
In pregnancy emphasis should be on:
• Preventing gingival disease before it occurs.
• Treating existing gingival disease before it becomes worse.
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of surgical excision,

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CARDIOVASCULAR DISEASES
Arteriosclerosis
In aged individuals, arteriosclerotic changes in the blood vessels are
characterized by,
initial thickening,
narrowing of lumen,
thickening & hyalinization of media and adventitia

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Congenital Heart Disease
oral changes includes
purplish-red discoloration of the lips and gingiva
sometimes severe marginal gingivitis
periodontal destruction.
The tongue appears coated, fissured and edematous
extreme reddening of the fungiform and filliform papillae

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HIV gingivitis:
In HIV gingivitis persistent, linear, easily bleeding, erythematous gingivitis.
lesions may be localized or generalized in nature.
HIV periodontitis: NUP (Necrotizing ulcerative periodontitis)
characterized by soft tissue necrosis
rapid periodontal destruction, marked interproximal bone loss.
severely painful at onset.

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Treatment:
a. Instruct the patient to perform meticulous oral hygiene.
b. Scale and polish affected areas.
c. Prescribe chlorhexidine gluconate mouth rinse.
d. Reevaluation and frequent recall visits.
e. Systemic antibiotics.
f.prophylactic antifungal medication should be considered.

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Metal Toxications
Ingestion of metals such as mercury, lead, bismuth may result in oral
manifestations
Bismuth Intoxication
gastrointestinal disturbances,
nausea, vomiting and jaundice
ulcerative gingivostomatitis
metallic taste and a burning sensation of the oral mucosa.
The tongue may be sore and inflamed.
Urticaria, and different types, bullous and purpuric lesions
bluish-black discoloration of the gingival margin

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Lead Intoxication
increased salivation,
coated-tongue,
peculiar sweetish taste,
gingival pigmentation and ulceration.
steel gray dicoloration, associated with local irritation.

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Mercury Intoxication
ulceration of the gingiva
destruction of underlying bone
Other Chemicals may cause necrosis of the alveolar bone with loosening and
exfoliation of teeth
Phosphorus
arsenic
chromium