Systemic Factors Influencing Periodontal Diseases Lecture PDF

Systemic Factors Influencing Periodontal Diseases DH 308 1  Systemic risk factors are conditions or diseases that increase an individual’s susceptibility to periodontal infection by modifying or amplifying the host response to microbial infection. 2 ...

Systemic Factors Influencing Periodontal Diseases DH 308 1  Systemic risk factors are conditions or diseases that increase an individual’s susceptibility to periodontal infection by modifying or amplifying the host response to microbial infection. 2  The relationship between periodontal disease and systemic disease is very often bidirectional: Certain systemic diseases/conditions are risk factors for more severe periodontal disease Periodontal inflammation may play a role in the etiology of some systemic diseases/conditions 3  Examples of Systemic Risk Factors Tobacco use Stress Diabetes mellitus Hormonal variations Metabolic Neutropenia Syndrome Down syndrome Leukemia Medication side effects HIV-Infection Sli de 4  Smokers are...  Two to three times more at risk for periodontal disease  Likely to lose more teeth than nonsmokers  More likely to exhibit attachment loss and periodontal destruction than former and never smokers 5  Epidemiology of Tobacco in Periodontal Patients Cigarette smoking is a very strong risk factor for periodontal disease Cigar and pipe smoking are significant risk factors for attachment loss Smokeless tobacco is associated with severe recession and loss of buccal attachment where the “plug” is placed 6  Smoking Smoking may be responsible for about 50% of cases of periodontal disease among adults in the United States. Heavy smokers (more than 10 cigarettes/day) have greater odds for more severe attachment loss. 7  Oral Problems With Smoking Halitosis Dry mouth Dental staining Periodontal disease Cancer 8  Heavy Staining and Biofilm Accumulation 9  Effects of Smoking on the Periodontium 10 11  Impact of Smoking on Oral Microbial Biofilms Biofilm may be colonized with more potential periodontal pathogens like Porphyromonas gingivalis Favorable environment for growth of anaerobic bacteria in pockets Depletes beneficial bacteria like Treponema Favors early acquisition and colonization of periodontal pathogens in oral biofilms 12  Impact of Smoking on Immune System  Affects both human immune system and inflammatory response system  Smokers have decreased signs of inflammation and impaired gingival blood flow – vasoconstrictor  Neutrophil function impaired  May decrease antibody production 13  Smoking and Bone Metabolism  Associated with greater amount of alveolar bone destruction than nonsmokers  Nicotine may suppress osteoblasts  Nicotine increases secretion of IL-6  May alter normal bone remodeling 14  Electronic Cigarettes  E-cigarettes introduced in U.S. market in 2007  Don’t contain tobacco  Mechanism heats up liquid nicotine, turning into a vapor  Vapor is inhaled and exhaled  U.S. FDA shows that the fluid and aerosol contains known toxins  Possible side effects of vapor unknown at this time  More research is needed in the long term use of E- cigarettes 15  Waterpipe Smoking Also known as Hookah and Shisha Use of a water pipe is associated with respiratory and cardiovascular problems Has a significant impact on the oral cavity Has significant amounts of nicotine and 27 known carcinogens Waterpipe smokers inhale over 40 L of smoke in a session compared to 1 L of smoke for a single cigarette Associated with an increase in periodontal pocket depths, loss of clinical attachment, and bone loss. 16  Smokeless Tobacco  Results in an increased inflammatory response in the tissues  Increased inflammatory responses contribute to accelerated breakdown of the periodontium and gingival recession at site of placement 17  Effects of Smoking on Periodontal Therapy  Chemical products and toxins in tobacco smoke may delay wound healing  Negative effect on fibroblasts and collagen production  Smokers have less reduction in probing depths  Gain less clinical attachment after treatment 18  Diabetes Mellitus 19  Diabetes is a chronic, lifelong metabolic disorder in which the body does not produce and/or properly use insulin Insulin is a hormone needed to convert sugar, starches and other food into energy that the body uses to sustain life. 20  Major Complications of Diabe tes Retinopathy Foot healing Cardiovascular diseases Nephropaty Neuropathy Periodontal disease Hearing loss 21  Diabetes in Numbers  Estimated Number of Cases in the US: An estimated 30.3 million people have diabetes (9.4 percent of the U.S. population)*  Diagnosed: An estimated 23.1 million people have been diagnosed with diabetes (7.2 percent of the U.S. population)*  Undiagnosed: An estimated 7.2 million adults, ages 18 years or older are undiagnosed (23.8 percent of people with diabetes)*  WHO predicts number of adult diabetics will rise to 366 million by 2030 and be the 7th leading cause of death  According to the CDC, over 88 million American adults have prediabetes  1 in 3 adults!  Of those 88 million, more than 8 in 10 are not aware of the condition. *Data from the National Institute of Diabetes and Digestive and Kidney Diseases **National Health and Nutrition Examination Survey 22  Diabetes Relationship to Periodontal Disease Prevalence of periodontitis is higher and symptoms more severe in individuals with diabetes mellitus compared with nondiabetics Findings from studies indicate that diabetes mellitus leads to a hyperinflammatory response to oral microbial biofilms and impairs resolution of inflammation and repair 23  Types of Diabetes Mellitus Three types of diabetes 5% to 10% of type I is caused by damage to pancreas. 90% to 95% of type II develops when the body does not make enough insulin. Gestational occurs during pregnancy.  Studies show that these patients are at an increased risk to develop type II diabetes later in life 24  Diabetes Mellitus (cont.) Individuals with well-controlled diabetes have no increased risk for periodontal disease than persons without diabetes. Individuals with poorly controlled diabetes are 3x more likely to develop periodontitis Individuals with diabetes and who smoke are 20x more likely than nondiabetics to experience severe periodontitis 25  Glucose Blood Levels in Diabetes Test Glucose Levels Hemoglobin The goal for most individuals with diabetes is a Alc glucose level less than 7%. High susceptibility to infection occurs when the glucose level is above 8%. Finger-Stick Glucose level at appointment time Target range = 80 to 120 mg/dL Increased risk of infection = 180–300 g/dL Unacceptable range = greater than 300 mg/dL Copyright © 2019 Wolters Kluwer All Rights Reserved  Subgingival Microbiota in Diabetics Composition of subgingival microbiota in a diabetic patient is no different than that found in a nondiabetic patient Diabetes does not favor or influence growth of a specific periodontal pathogen 27  Wound Healing in Diabetics Unfavorable treatment outcome may occur in long-term maintenance therapy in individuals with poorly controlled diabetes Poorer response to nonsurgical and surgical periodontal therapies More rapid recurrence of deep pockets 28  Other Oral Complications of Poorly Controlled Diabetes Mellitus Reduced salivary flow Encourages growth of Candida Albicans Greater formation of dental caries Multiple abscess formation Rapid destruction of alveolar bone Cheilosis Burning mouth and tongue 29  Localized Tissue Swelling (Lateral Incisor) in an Individual With Uncontrolled Diabetes 30 31  Periodontitis With Uncontrolled Diabetes 32  Effects of Uncontrolled Diabetes 33  Altered Inflammatory Response Defective neutrophilic function in diabetics impairs initial immune response to infection Hyperresponsive monocytes/macrophages in diabetics elevates production of proinflammatory cytokines Proinflammatory cytokines may initiate and worsen the spread to other organ systems and cause other systemic conditions, like cardiovascular disease 34  Imbalanced Bone Destruction and Repair Rapid alveolar bone loss seen in individuals with diabetes may result from uncoupling of activities of osteoblasts and osteoclasts Prolonged osteoclastic formation and activity increases programmed cell death of osteoblasts Impairs bone formation following bone resorption 35 Stress  Stress as a Risk Factor for Periodontal Disease Acute stress can be immunoenhancing Chronic stress can impair physiologic regulatory mechanism that governs the immune system Hormone cortisol has anti-inflammatory and immunosuppressive properties Blood levels of cortisol become elevated in response to physical and psychological stress 37  Stress: Implications for the Dental Hygienist Prolonged or intense periods of stress can cause suppression of the immune system This might tip the host-microbial interaction in favor of bacteria causing attachment loss Stress can alter how people look after themselves Make patients aware of potential effects of stress on general and oral health 38 39  Hormonal Variations 40  Hormone Alteration Changes in hormone levels may have an effect on the periodontium. Levels of sex hormones vary throughout life – Puberty – Pregnancy – Menopause 41  Puberty Increase in hormones causes increased blood circulation to gingival tissues. Increased levels may cause increased sensitivity to local irritants such as biofilm. Pubertal gingivitis occurs equally in males and females. 42  Pregnancy If self-care good before pregnancy and the patient continues to practice good oral hygiene, there is usually no problem Usually occurs in patients who have gingivitis before becoming pregnant Inflammation of gingiva increases in pregnancy even in the presence of small amounts of biofilm 43  Pregnancy (cont.) Gingival inflammation increases in 2 nd and 3rd trimesters when elevated estrogen levels in blood exaggerate host response to biofilm Second trimester associated with increased levels of Prevotella intermedia (P. intermedia) P. intermedia uses estrogen as a substitute for natural growth factor 44  Pregnancy (cont.) Elevated progesterone levels enhance capillary permeability and dilation resulting in increased gingival exudate and edema High levels of progesterone and estrogen associated with pregnancy suppress immune response to dental biofilm 45  Pregnancy Gingivitis Gingival tissues appear edematous and dark red with bulbous interdental papillae 46  Pyogenic Granuloma (Pregnancy Tumor) Papilla reacts strongly to the biofilm A tumor-like proliferation on the interdental gingiva or gingival margin Noncancerous Not painful 47  Pregnancy-Associated Pyogenic Granuloma Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 48  Premature Labor and Low-Birt h-Weight  (PLBW) Research suggests that periodontal pathogens can enter the bloodstream affecting the developing fetus, and potentially leading to premature labor and low-birth-weight (PLBW) babies. 49  Menopause and Postmenopause Decreased levels of circulating hormones in menopausal and postmenopausal women result in oral changes. Dry mouth Burning sensation Altered taste Bone loss may be exacerbated 50  Menopausal Gingivostomatitis Menopausal gingivostomatitis is characterized by gingiva that bleeds readily with abnormally pale, dry, and shiny erythematous appearance. 51 52 53  Medication-Induced Osteonecrosis ofBisphosphonates  the Jaw (ONJ) are most commonly prescribed medication to inhibit systemic bone resorption Bisphosphonates cause a rare disorder called ONJ ONJ is characterized by painful exposed bone in the mouth that fails to heal after extraction or oral surgery 54  Medication-Induced Osteonecrosis ofBethe  Jaw aware (ONJ) risk of ONJ: of increased IV Bisphosphonates used for cancer treatment Patients taking Bisphosphonates to treat osteoporosis for more than 3 years In doubt, consult with your Instructor, or contact pt’s physician. 55  Metabolic Syndrome 56  Metabolic Syndrome Closely related metabolic disturbances that occur together, increasing risk of heart disease, stroke and diabetes: – Increased blood pressure – High blood sugar – Excess body fat around the waist – Abnormal cholesterol or triglyceride levels – Proinflammatory state – Increased tendency toward thrombosis 57  Metabolic Syndrome Greater prevalence in older populations In the United States, one out of three adults have it Has an impact on periodontal status via chronic low-grade inflammation of prolonged duration Adipocytes (fat cells) release adipokines which cause sustained inflammation, insulin resistance and increased susceptibility to periodontitis Hypertension impairs blood flow that supplies periodontium 58 59  Acquired Immunodeficiency Syndrome 60  HIV-Infection Acquired immunodeficiency syndrome (AIDS) is a communicable disease caused by the HIV virus Has a profound effect on cellular immunity Increased periodontal attachment loss in HIV- infected individuals 61  Periodontal and Oral Manifestations of HIV Infection Hairy Leukoplakia Candidiasis Herpes labialis Herpes zoster Recurrent aphthous ulcers Kaposi sarcoma Linear Gingival Erythema 62  Linear Gingival Erythema (LGE) Characterized by a 2--3 mm marginal band of intense erythema, usually in the free gingiva, but may extend to attached gingiva or beyond mucogingival line into alveolar mucosa Intensity of inflammation is exaggerated in relation to amount of biofilm present Not associated with pocketing Does not affect clinical attachment levels or alveolar bone levels 63  Linear Gingival Erythema 64  HIV-Infected Individuals: Implications for the Dental Hygienist Safe to perform periodontal therapy as long as the immune system is competent LGE is treated with standard periodontal therapy plus use of chlorhexidine gluconate Frequent maintenance visits Stress meticulous self-care Coordinate care with other health care professionals 65  Neutropenia 66  Neutropenia Characterized by abnormally few numbers of neutrophils in blood Lower than 1500 cells/µL of blood Leads to increased susceptibility for infection Can be the result of bone marrow failure May be congenital 67  Neutropenia and Periodontitis PMNs are first responders to fight off microbial invasion---fewer means poor immunity Consider patients with this disorder as being immunocompromised 68 69  Down Syndrome 70  Down Syndrome Genetic disorder that happens before birth Nucleus contains 47 vs 46 chromosomes Usually 3 copies of the 21st chromosome Also called trisomy 21 Lifelong Varies in severity Causes intellectual disability and developmental delays 71  Characteristic Facial Features of Down Syndrome Underdeveloped midfacial region Palate may appear highly vaulted and narrow due to unusual thickness of sides of palate Lips may be large and thick with decreased muscle tone causing drooling Tongue may appear cracked with fissures Malocclusion due to delayed eruption 72  Medical Concerns of Down Syndrome Increased risk for congenital heart defects Susceptibility to infection Respiratory problems GI abnormalities Leukemia Abnormal number of PMNs Mild to moderate mental retardation 73  Down Syndrome and Periodontitis Often develop rapidly progressive periodontitis Substantial biofilm formation Periodontal pathogens colonize gingival tissues in early childhood years; may lead to loss of permanent anterior teeth 74 75  Leukemia 76  Leukemia-Associated Gingivitis Signs in the gingiva – Swollen, glazed, spongy tissues – Red to deep purple in color Gingival enlargement is occasionally seen. 77  Oral Mucositis Inflammation of oral mucous membranes caused when chemotherapy attacks and kills the rapidly dividing cells of the mucous membranes Cells die faster than usual 10--14 days Sloughing of mucosa can be localized or generalized 78  Xerostomia Occurs when salivary glands are damaged during radiation therapy Reduced flow of saliva encourages growth of Candida albicans, which causes oral candidiasis 79  Leukemia: Implications for the Dental Hygienist Look for spontaneous gingival bleeding and gingival enlargement for no apparent reason If oral signs seen first in the dental office, refer to a physician Good oral care is necessary to prevent the spread of serious infections from the oral cavity to other parts of the body Chemotherapy causes sore and sensitive mouth that bleeds easily 80  Pain Management Topical anesthetics have limited success Prophylactic use of chlorhexidine may reduce frequency of oral mucositis and oral pathogens 81  Leukemia-Associated Gingivitis 82  Effects of Oral Medications A number of medications used to treat systemic conditions can cause oral complications.  Alteration of biofilm composition or pH  Effect on salivary flow  Effect on gingival tissues 83  Xerostomic Effects More than 400 over-the-counter and prescription drugs reduce salivary flow. Some common medications causing xerostomia are blood pressure medicines, diuretics, and antidepressants. 84  Xerostomic Effects (cont.) Patients with xerostomia suffer from an increase in: Oral candidiasis Root surface caries Excess biofilm formation 85  Reduced Salivary Flow Drugs with xerostomic effects: Antihypertensives Narcotic analgesics Tranquilizers Diuretics Antimetabolites Antihistamines Sedatives 86  Overgrowth of the Gingival Tissues The most dramatic medication-related change seen in the gingiva is gingival hyperplasia. Drug-influenced gingival hyperplasia is an overgrowth of the gingiva that is a side effect associated with certain medications. 87 Gingival Overgrowth Overgrowth begins in the interdental papillae area. Enlarged papillae fuse mesially and distally and partially cover the anatomical Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins crown. Copyright © 2019 Wolters Kluwer All Rights Reserved 88  Medications and Gingival Enlargement 20 medications have the potential to trigger gingival hyperplasia. Three major classes Anticonvulsants Immunosuppressives Calcium channel blockers 89  Phenytoin (FEN-i-toyn) It is the most commonly used anticonvulsant medication to control convulsions and seizures in the treatment of individuals with epilepsy. Gingival hyperplasia is the most common side effect. Overgrowths are common in children and young adults taking the drug. 90  Phenytoin (cont.) It is marketed under various trade names including Dilantin 4 Dilantin Kapseals 4 It is among the 20 most-prescribed drugs in the world! 91  Phenytoin-Influenced Gingival Hyperplasia 92  Phenytoin (cont.) Scrupulous home care reduces the incidence of gingival hyperplasia in patients who take phenytoin. 93  Cyclosporine (SIGH-kloe-spor- een) Immunosuppressive agent Reduces body’s immune response in organ transplants Gingival hyperplasia occurs in 25% of those taking the medication. Gingival hyperplasia resembles that from phenytoin. 94  Cyclosporine-Influenced Gingival Overgrowth 95  Nifedipine (nye-FED-I-peen) Calcium channel blocker Coronary vasodilator used to treat people with hypertension, angina, and cardiac arrhythmias 38% patients taking the drug experience gingival enlargement. Gingival overgrowth resembles that from phenytoin. 96  Nifedipine-Associated Gingival Enlargement 97  Questions? 98